Healthcare Provider Details

I. General information

NPI: 1063961357
Provider Name (Legal Business Name): RICKY KENNEDY LPC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/27/2016
Last Update Date: 10/12/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1001 W MAIN ST
DURANT OK
74701-5038
US

IV. Provider business mailing address

1001 W MAIN ST
DURANT OK
74701-5038
US

V. Phone/Fax

Practice location:
  • Phone: 580-924-7330
  • Fax:
Mailing address:
  • Phone: 580-924-7330
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number14492
License Number StateTX
# 2
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number6267
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: