Provider Demographics
NPI:1710492913
Name:PICKERRELL, TIMOTHY P (LCSW-I)
Entity Type:Individual
Prefix:MR
First Name:TIMOTHY
Middle Name:P
Last Name:PICKERRELL
Suffix:
Gender:M
Credentials:LCSW-I
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:133 INTEGRA BREEZE LN UNIT 104
Mailing Address - Street 2:
Mailing Address - City:DAYTONA BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32117-5584
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:133 INTEGRA BREEZE LN UNIT 104
Practice Address - Street 2:
Practice Address - City:DAYTONA BEACH
Practice Address - State:FL
Practice Address - Zip Code:32117-5584
Practice Address - Country:US
Practice Address - Phone:270-401-6905
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-12-11
Last Update Date:2017-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty