Provider Demographics
NPI:1174680250
Name:PICKETT, DIANE (PHD)
Entity Type:Individual
Prefix:DR
First Name:DIANE
Middle Name:
Last Name:PICKETT
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:55 NEW MONTGOMERY ST
Mailing Address - Street 2:STE 420
Mailing Address - City:SAN FRANCISCO
Mailing Address - State:CA
Mailing Address - Zip Code:94105-3429
Mailing Address - Country:US
Mailing Address - Phone:415-945-0211
Mailing Address - Fax:415-945-0212
Practice Address - Street 1:55 NEW MONTGOMERY ST
Practice Address - Street 2:STE 424
Practice Address - City:SAN FRANCISCO
Practice Address - State:CA
Practice Address - Zip Code:94105-3429
Practice Address - Country:US
Practice Address - Phone:415-945-0211
Practice Address - Fax:415-945-0212
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-02
Last Update Date:2018-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY 11097103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAS52019Medicare UPIN
CAOPL110971Medicare ID - Type Unspecified