Provider Demographics
NPI:1659602092
Name:PICKERING, GARY R (MDIV MS)
Entity Type:Individual
Prefix:MR
First Name:GARY
Middle Name:R
Last Name:PICKERING
Suffix:
Gender:M
Credentials:MDIV MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:35120 MILLROCK ST
Mailing Address - Street 2:
Mailing Address - City:WEBSTER
Mailing Address - State:FL
Mailing Address - Zip Code:33597-9067
Mailing Address - Country:US
Mailing Address - Phone:352-438-4847
Mailing Address - Fax:
Practice Address - Street 1:106 S MAIN ST
Practice Address - Street 2:
Practice Address - City:BUSHNELL
Practice Address - State:FL
Practice Address - Zip Code:33513-7306
Practice Address - Country:US
Practice Address - Phone:352-438-4847
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-01-25
Last Update Date:2010-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMH 9960101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health