Provider Demographics
NPI:1134362049
Name:PRICE, RICKY G (MS, LPC)
Entity type:Individual
Prefix:
First Name:RICKY
Middle Name:G
Last Name:PRICE
Suffix:
Gender:M
Credentials:MS, LPC
Other - Prefix:
Other - First Name:RICK
Other - Middle Name:G
Other - Last Name:PRICE
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MS, LPC
Mailing Address - Street 1:19 MYRTLE ST
Mailing Address - Street 2:
Mailing Address - City:MEDFORD
Mailing Address - State:OR
Mailing Address - Zip Code:97504-7337
Mailing Address - Country:US
Mailing Address - Phone:541-842-7626
Mailing Address - Fax:541-842-7640
Practice Address - Street 1:722 LAUREL AVE
Practice Address - Street 2:
Practice Address - City:BUTTE FALLS
Practice Address - State:OR
Practice Address - Zip Code:97522-0244
Practice Address - Country:US
Practice Address - Phone:541-842-7799
Practice Address - Fax:541-842-7798
Is Sole Proprietor?:Yes
Enumeration Date:2009-04-08
Last Update Date:2013-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORC3129101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR227698Medicaid