Provider Demographics
NPI:1699190074
Name:PICKENS, CYNTHIA
Entity Type:Individual
Prefix:
First Name:CYNTHIA
Middle Name:
Last Name:PICKENS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1300 HOPPE BLVD STE 1
Mailing Address - Street 2:
Mailing Address - City:ADA
Mailing Address - State:OK
Mailing Address - Zip Code:74820-2319
Mailing Address - Country:US
Mailing Address - Phone:580-436-7269
Mailing Address - Fax:
Practice Address - Street 1:777 CASINO AVE
Practice Address - Street 2:
Practice Address - City:THACKERVILLE
Practice Address - State:OK
Practice Address - Zip Code:73459-9774
Practice Address - Country:US
Practice Address - Phone:580-272-5170
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-02-21
Last Update Date:2022-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100709510AMedicaid