Provider Demographics
NPI:1679104442
Name:RICKETTS, ROY
Entity type:Individual
Prefix:
First Name:ROY
Middle Name:
Last Name:RICKETTS
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 1:5520 OATFIELD ST
Mailing Address - Street 2:
Mailing Address - City:N LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89081-2979
Mailing Address - Country:US
Mailing Address - Phone:702-886-7044
Mailing Address - Fax:
Practice Address - Street 1:5520 OATFIELD ST
Practice Address - Street 2:
Practice Address - City:N LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89081-2979
Practice Address - Country:US
Practice Address - Phone:702-886-7044
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-01-30
Last Update Date:2020-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician