Provider Demographics
NPI:1457506263
Name:PICKETT, SUSAN STEVENS (PSYD)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:STEVENS
Last Name:PICKETT
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10 PINCKNEY COLONY RD
Mailing Address - Street 2:BUILDING 300, SUITE 303
Mailing Address - City:BLUFFTON
Mailing Address - State:SC
Mailing Address - Zip Code:29909-4126
Mailing Address - Country:US
Mailing Address - Phone:843-815-8588
Mailing Address - Fax:843-815-8573
Practice Address - Street 1:10 PINCKNEY COLONY ROAD
Practice Address - Street 2:BLDG 300
Practice Address - City:BLUFFTON
Practice Address - State:SC
Practice Address - Zip Code:29909-4126
Practice Address - Country:US
Practice Address - Phone:843-422-5504
Practice Address - Fax:843-815-8573
Is Sole Proprietor?:Yes
Enumeration Date:2008-11-20
Last Update Date:2017-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC1090103TC2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & Adolescent
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCPS0456Medicaid
SCPS0456Medicaid