Provider Demographics
NPI:1033636691
Name:PICKETT, TERRELL DONNELL
Entity Type:Individual
Prefix:
First Name:TERRELL
Middle Name:DONNELL
Last Name:PICKETT
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:PO BOX 16906
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85011-6906
Mailing Address - Country:US
Mailing Address - Phone:602-279-1427
Mailing Address - Fax:
Practice Address - Street 1:22490 N VANDERVEEN WAY
Practice Address - Street 2:
Practice Address - City:MARICOPA
Practice Address - State:AZ
Practice Address - Zip Code:85138-5569
Practice Address - Country:US
Practice Address - Phone:623-826-4195
Practice Address - Fax:602-279-1431
Is Sole Proprietor?:No
Enumeration Date:2017-08-24
Last Update Date:2018-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ6426468OtherDCS/OLR