Provider Demographics
NPI:1275700668
Name:PICKWORTH, CYNTHIA ANN
Entity Type:Individual
Prefix:
First Name:CYNTHIA
Middle Name:ANN
Last Name:PICKWORTH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1395 BINGHAM DR
Mailing Address - Street 2:
Mailing Address - City:DE PERE
Mailing Address - State:WI
Mailing Address - Zip Code:54115-4063
Mailing Address - Country:US
Mailing Address - Phone:920-632-4885
Mailing Address - Fax:
Practice Address - Street 1:200 S 9TH ST
Practice Address - Street 2:
Practice Address - City:DE PERE
Practice Address - State:WI
Practice Address - Zip Code:54115-1393
Practice Address - Country:US
Practice Address - Phone:920-632-4885
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-05-14
Last Update Date:2008-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI10894-024225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist