Provider Demographics
NPI:1619442076
Name:PICKETT, PAUL JR
Entity Type:Individual
Prefix:MR
First Name:PAUL
Middle Name:
Last Name:PICKETT
Suffix:JR
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4708 TWISTED OAKS RD APT 104
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28212-7317
Mailing Address - Country:US
Mailing Address - Phone:704-456-8120
Mailing Address - Fax:704-509-9208
Practice Address - Street 1:4708 TWISTED OAKS RD APT 104
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28212-7317
Practice Address - Country:US
Practice Address - Phone:704-456-8120
Practice Address - Fax:704-509-9208
Is Sole Proprietor?:No
Enumeration Date:2018-10-11
Last Update Date:2020-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC103TM1800X
372600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes372600000XNursing Service Related ProvidersAdult Companion
No103TM1800XBehavioral Health & Social Service ProvidersPsychologistIntellectual & Developmental Disabilities
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC1619442076Medicaid