Provider Demographics
NPI:1487950788
Name:SHORT, RICKEY DEAN (LADC)
Entity type:Individual
Prefix:MR
First Name:RICKEY
Middle Name:DEAN
Last Name:SHORT
Suffix:
Gender:M
Credentials:LADC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4105 QUAIL DR
Mailing Address - Street 2:
Mailing Address - City:NORMAN
Mailing Address - State:OK
Mailing Address - Zip Code:73072-4518
Mailing Address - Country:US
Mailing Address - Phone:405-447-8519
Mailing Address - Fax:405-447-0739
Practice Address - Street 1:3750 W MAIN ST
Practice Address - Street 2:SUITE 206
Practice Address - City:NORMAN
Practice Address - State:OK
Practice Address - Zip Code:73072-4657
Practice Address - Country:US
Practice Address - Phone:405-447-8519
Practice Address - Fax:405-447-0739
Is Sole Proprietor?:Yes
Enumeration Date:2011-02-03
Last Update Date:2011-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK94101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)