Provider Demographics
NPI:1336734649
Name:BATES, RICKEY LEE (PHD)
Entity Type:Individual
Prefix:DR
First Name:RICKEY
Middle Name:LEE
Last Name:BATES
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 1:1375 AGNES PL
Mailing Address - Street 2:
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38104-4725
Mailing Address - Country:US
Mailing Address - Phone:901-218-1612
Mailing Address - Fax:
Practice Address - Street 1:1030 JEFFERSON AVE
Practice Address - Street 2:
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38104-2127
Practice Address - Country:US
Practice Address - Phone:901-523-8990
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-03-08
Last Update Date:2021-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN3738103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Multi-Specialty