Provider Demographics
NPI:1609917293
Name:PICKETT, BRENDA (LCSW)
Entity Type:Individual
Prefix:
First Name:BRENDA
Middle Name:
Last Name:PICKETT
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2674 W DEERFIELD CT
Mailing Address - Street 2:
Mailing Address - City:EAGLE
Mailing Address - State:ID
Mailing Address - Zip Code:83616-2339
Mailing Address - Country:US
Mailing Address - Phone:208-794-4097
Mailing Address - Fax:208-939-9110
Practice Address - Street 1:136 S ACADEMY AVE
Practice Address - Street 2:
Practice Address - City:EAGLE
Practice Address - State:ID
Practice Address - Zip Code:83616-6541
Practice Address - Country:US
Practice Address - Phone:208-794-4097
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDLCSW-826101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID826OtherLSCW