1457506263 NPI number — SUSAN STEVENS PICKETT PSY.D.

Table of content: SUSAN STEVENS PICKETT PSY.D. (NPI 1457506263)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1457506263 NPI number — SUSAN STEVENS PICKETT PSY.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
PICKETT
Provider First Name:
SUSAN
Provider Middle Name:
STEVENS
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
PSY.D.
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1457506263
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
11/21/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
10 PINCKNEY COLONY RD
Provider Second Line Business Mailing Address:
BUILDING 300, SUITE 303
Provider Business Mailing Address City Name:
BLUFFTON
Provider Business Mailing Address State Name:
SC
Provider Business Mailing Address Postal Code:
29909-4126
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
843-815-8588
Provider Business Mailing Address Fax Number:
843-815-8573

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
10 PINCKNEY COLONY ROAD
Provider Second Line Business Practice Location Address:
BLDG 300
Provider Business Practice Location Address City Name:
BLUFFTON
Provider Business Practice Location Address State Name:
SC
Provider Business Practice Location Address Postal Code:
29909-4126
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
843-422-5504
Provider Business Practice Location Address Fax Number:
843-815-8573
Provider Enumeration Date:
11/20/2008

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 103TC2200X , with the licence number:  1090 , registered in the state of SC ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: PS0456 , issued by the state of ( SC ) . This identifiers is of the category "MEDICAID".




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