Provider Demographics
NPI:1295213932
Name:PICKENS, KIMBERLY SUZANNE (MOT)
Entity Type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:SUZANNE
Last Name:PICKENS
Suffix:
Gender:F
Credentials:MOT
Other - Prefix:
Other - First Name:KIMBERLY
Other - Middle Name:SUZANNE
Other - Last Name:PARKER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MOT
Mailing Address - Street 1:18211 KELLY BLVD APT 1111
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75287-4681
Mailing Address - Country:US
Mailing Address - Phone:405-496-2896
Mailing Address - Fax:
Practice Address - Street 1:2535 LONE STAR DR
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75212-6313
Practice Address - Country:US
Practice Address - Phone:214-467-9787
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-08-03
Last Update Date:2018-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX117036225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist