Provider Demographics
NPI:1609408897
Name:FICKLIN, SABRINA RENEA
Entity Type:Individual
Prefix:
First Name:SABRINA
Middle Name:RENEA
Last Name:FICKLIN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1021 8TH AVE NW
Mailing Address - Street 2:
Mailing Address - City:ARDMORE
Mailing Address - State:OK
Mailing Address - Zip Code:73401-4015
Mailing Address - Country:US
Mailing Address - Phone:580-220-0857
Mailing Address - Fax:
Practice Address - Street 1:1021 8TH AVE NW
Practice Address - Street 2:
Practice Address - City:ARDMORE
Practice Address - State:OK
Practice Address - Zip Code:73401-4015
Practice Address - Country:US
Practice Address - Phone:580-220-0857
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-02-06
Last Update Date:2020-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OKM080989998106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior TechnicianGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OKM080989998OtherSTATE OF OKLAHOMA