Provider Demographics
NPI:1629203880
Name:PICKENS, SONRIE GERVACIO (PT, DPT, OCS)
Entity Type:Individual
Prefix:
First Name:SONRIE
Middle Name:GERVACIO
Last Name:PICKENS
Suffix:
Gender:F
Credentials:PT, DPT, OCS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1100 WILLFORD HALL LOOP
Mailing Address - Street 2:BLDG 4554
Mailing Address - City:JBSA-LACKLAND
Mailing Address - State:TX
Mailing Address - Zip Code:78236
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1100 WILLFORD HALL LOOP
Practice Address - Street 2:BLDG 4554
Practice Address - City:JBSA-LACKLAND
Practice Address - State:TX
Practice Address - Zip Code:78236
Practice Address - Country:US
Practice Address - Phone:210-292-0303
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-05-18
Last Update Date:2019-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
171000000X
TX1188926225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
No171000000XOther Service ProvidersMilitary Health Care Provider