Provider Demographics
NPI:1407227952
Name:MATTOX, RICKY
Entity Type:Individual
Prefix:
First Name:RICKY
Middle Name:
Last Name:MATTOX
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:425 N MAYSVILLE ST
Mailing Address - Street 2:
Mailing Address - City:MT STERLING
Mailing Address - State:KY
Mailing Address - Zip Code:40353-1050
Mailing Address - Country:US
Mailing Address - Phone:859-497-0594
Mailing Address - Fax:859-432-1025
Practice Address - Street 1:425 N MAYSVILLE ST
Practice Address - Street 2:
Practice Address - City:MT STERLING
Practice Address - State:KY
Practice Address - Zip Code:40353-1050
Practice Address - Country:US
Practice Address - Phone:859-497-0594
Practice Address - Fax:859-432-1025
Is Sole Proprietor?:No
Enumeration Date:2015-10-09
Last Update Date:2020-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY242014101YM0800X, 106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health