Provider Demographics
NPI:1568902302
Name:PICKENS, TERI (LSW DD)
Entity Type:Individual
Prefix:
First Name:TERI
Middle Name:
Last Name:PICKENS
Suffix:
Gender:F
Credentials:LSW DD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:143 E RIDGEWOOD AVE#1345
Mailing Address - Street 2:
Mailing Address - City:RIDGEWOOD
Mailing Address - State:NJ
Mailing Address - Zip Code:07451-1345
Mailing Address - Country:US
Mailing Address - Phone:201-739-8759
Mailing Address - Fax:
Practice Address - Street 1:143 E RIDGEWOOD AVE#1345
Practice Address - Street 2:
Practice Address - City:RIDGEWOOD
Practice Address - State:NJ
Practice Address - Zip Code:07451-1345
Practice Address - Country:US
Practice Address - Phone:201-739-8759
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-02-27
Last Update Date:2017-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ44SL04726700171W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor