Provider Demographics
NPI:1437270410
Name:KIMES, RICKY CORDALE (MA LPC)
Entity Type:Individual
Prefix:MR
First Name:RICKY
Middle Name:CORDALE
Last Name:KIMES
Suffix:
Gender:M
Credentials:MA LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:105 OAKTREE LN APT 6
Mailing Address - Street 2:
Mailing Address - City:ROLLA
Mailing Address - State:MO
Mailing Address - Zip Code:65401-4622
Mailing Address - Country:US
Mailing Address - Phone:573-202-0679
Mailing Address - Fax:
Practice Address - Street 1:13160 COUNTY ROAD 3610
Practice Address - Street 2:
Practice Address - City:ST. JAMES
Practice Address - State:MO
Practice Address - Zip Code:65559
Practice Address - Country:US
Practice Address - Phone:573-265-3251
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-04-03
Last Update Date:2009-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2007008468101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional