Provider Demographics
NPI:1053657296
Name:PICKUP, DEREK JAMES (LMSW)
Entity Type:Individual
Prefix:MR
First Name:DEREK
Middle Name:JAMES
Last Name:PICKUP
Suffix:
Gender:M
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:807 BLYTHWOOD RD
Mailing Address - Street 2:
Mailing Address - City:VALDOSTA
Mailing Address - State:GA
Mailing Address - Zip Code:31602-1666
Mailing Address - Country:US
Mailing Address - Phone:229-251-4638
Mailing Address - Fax:
Practice Address - Street 1:807 BLYTHWOOD RD
Practice Address - Street 2:
Practice Address - City:VALDOSTA
Practice Address - State:GA
Practice Address - Zip Code:31602-1666
Practice Address - Country:US
Practice Address - Phone:229-251-4638
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-12-17
Last Update Date:2012-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA005080104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA005080OtherNASW