Provider Demographics
NPI:1295394484
Name:PICKETT, AMBER WAITCUS (AUD)
Entity Type:Individual
Prefix:
First Name:AMBER
Middle Name:WAITCUS
Last Name:PICKETT
Suffix:
Gender:F
Credentials:AUD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:146 HAZARD AVE STE 204
Mailing Address - Street 2:
Mailing Address - City:ENFIELD
Mailing Address - State:CT
Mailing Address - Zip Code:06082-4566
Mailing Address - Country:US
Mailing Address - Phone:860-763-3243
Mailing Address - Fax:860-763-3244
Practice Address - Street 1:146 HAZARD AVE STE 204
Practice Address - Street 2:
Practice Address - City:ENFIELD
Practice Address - State:CT
Practice Address - Zip Code:06082-4566
Practice Address - Country:US
Practice Address - Phone:860-763-3243
Practice Address - Fax:860-763-3244
Is Sole Proprietor?:No
Enumeration Date:2019-06-11
Last Update Date:2020-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT648237600000X, 231H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes231H00000XSpeech, Language and Hearing Service ProvidersAudiologist
No237600000XSpeech, Language and Hearing Service ProvidersAudiologist-Hearing Aid Fitter