Provider Demographics
NPI:1184935280
Name:SPARKS, RICKEY JOE (PHD)
Entity type:Individual
Prefix:
First Name:RICKEY
Middle Name:JOE
Last Name:SPARKS
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:904 W SOUTH PARK BLVD
Mailing Address - Street 2:
Mailing Address - City:BROKEN ARROW
Mailing Address - State:OK
Mailing Address - Zip Code:74011-2042
Mailing Address - Country:US
Mailing Address - Phone:918-455-2714
Mailing Address - Fax:
Practice Address - Street 1:904 W SOUTH PARK BLVD
Practice Address - Street 2:
Practice Address - City:BROKEN ARROW
Practice Address - State:OK
Practice Address - Zip Code:74011-2042
Practice Address - Country:US
Practice Address - Phone:918-455-2714
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-06-23
Last Update Date:2010-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK391101YA0400X
OK1588101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)