Provider Demographics
NPI:1790057693
Name:PHILLIPS, RICKY JOE (PHD, LCC)
Entity Type:Individual
Prefix:DR
First Name:RICKY
Middle Name:JOE
Last Name:PHILLIPS
Suffix:
Gender:M
Credentials:PHD, LCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4346 TERRACE LN SE
Mailing Address - Street 2:
Mailing Address - City:KENTWOOD
Mailing Address - State:MI
Mailing Address - Zip Code:49512-5602
Mailing Address - Country:US
Mailing Address - Phone:616-427-3212
Mailing Address - Fax:
Practice Address - Street 1:4346 TERRACE LN SE
Practice Address - Street 2:
Practice Address - City:KENTWOOD
Practice Address - State:MI
Practice Address - Zip Code:49512-5602
Practice Address - Country:US
Practice Address - Phone:616-427-3212
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-02-07
Last Update Date:2012-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI1137101YP1600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP1600XBehavioral Health & Social Service ProvidersCounselorPastoral