Provider Demographics
NPI:1073155990
Name:PICKEN, AMANDA (LAC)
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:
Last Name:PICKEN
Suffix:
Gender:F
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4111 MARATHON BLVD STE 110
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78756-3753
Mailing Address - Country:US
Mailing Address - Phone:512-222-3198
Mailing Address - Fax:
Practice Address - Street 1:4111 MARATHON BLVD STE 110
Practice Address - Street 2:
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78756-3753
Practice Address - Country:US
Practice Address - Phone:512-222-3198
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-10-11
Last Update Date:2019-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXAC01935171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXAC01935OtherTEXAS MEDICAL BOARD