Provider Demographics
NPI:1356791222
Name:EVANS, RICKEY
Entity type:Individual
Prefix:MR
First Name:RICKEY
Middle Name:
Last Name:EVANS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4601 N MARKET ST STE 2
Mailing Address - Street 2:
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71107-2972
Mailing Address - Country:US
Mailing Address - Phone:318-424-8735
Mailing Address - Fax:318-424-8739
Practice Address - Street 1:4601 N MARKET ST STE 2
Practice Address - Street 2:
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71107-2972
Practice Address - Country:US
Practice Address - Phone:318-424-8735
Practice Address - Fax:318-424-8739
Is Sole Proprietor?:No
Enumeration Date:2016-06-21
Last Update Date:2016-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health