Provider Demographics
NPI:1487194825
Name:PICKARD, POLLY LYNN
Entity Type:Individual
Prefix:MS
First Name:POLLY
Middle Name:LYNN
Last Name:PICKARD
Suffix:
Gender:F
Credentials:
Other - Prefix:MS
Other - First Name:PAULA
Other - Middle Name:LYNN
Other - Last Name:PICKARD
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:237 WEDGEWOOD DR
Mailing Address - Street 2:
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71105-4115
Mailing Address - Country:US
Mailing Address - Phone:318-773-5606
Mailing Address - Fax:
Practice Address - Street 1:237 WEDGEWOOD DR
Practice Address - Street 2:
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71105-4115
Practice Address - Country:US
Practice Address - Phone:318-773-5606
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-03-05
Last Update Date:2017-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
10101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor