Provider Demographics
NPI:1922101120
Name:PHILLIPS, RICKEY LYNN JR (LCSW)
Entity Type:Individual
Prefix:MR
First Name:RICKEY
Middle Name:LYNN
Last Name:PHILLIPS
Suffix:JR
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4400 SHUFFIELD DR
Mailing Address - Street 2:
Mailing Address - City:LITTLE ROCK
Mailing Address - State:AR
Mailing Address - Zip Code:72205-7100
Mailing Address - Country:US
Mailing Address - Phone:501-686-9300
Mailing Address - Fax:
Practice Address - Street 1:4400 SHUFFIELD DR
Practice Address - Street 2:
Practice Address - City:LITTLE ROCK
Practice Address - State:AR
Practice Address - Zip Code:72205-7100
Practice Address - Country:US
Practice Address - Phone:501-686-9300
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-06
Last Update Date:2008-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR2187-C1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR116378726Medicaid
AR56979Medicare ID - Type Unspecified
AR5A745Medicare PIN