Provider Demographics
NPI:1467769752
Name:PICKARD, TANESHA S
Entity Type:Individual
Prefix:MS
First Name:TANESHA
Middle Name:S
Last Name:PICKARD
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 1:103 WOODLAND ST
Mailing Address - Street 2:4TH FLOOR
Mailing Address - City:HARTFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06105-1233
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:103 WOODLAND ST
Practice Address - Street 2:4TH FLOOR
Practice Address - City:HARTFORD
Practice Address - State:CT
Practice Address - Zip Code:06105-1233
Practice Address - Country:US
Practice Address - Phone:860-793-7204
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-09-08
Last Update Date:2010-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT177658320101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health