Provider Demographics
NPI:1811587801
Name:PICKERING, DALTON RYAN (LPC CANDIDATE)
Entity Type:Individual
Prefix:MR
First Name:DALTON
Middle Name:RYAN
Last Name:PICKERING
Suffix:
Gender:M
Credentials:LPC CANDIDATE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1322 E ALLEN RD APT 7
Mailing Address - Street 2:
Mailing Address - City:TAHLEQUAH
Mailing Address - State:OK
Mailing Address - Zip Code:74464-2251
Mailing Address - Country:US
Mailing Address - Phone:580-559-6450
Mailing Address - Fax:
Practice Address - Street 1:711 S MUSKOGEE AVE
Practice Address - Street 2:
Practice Address - City:TAHLEQUAH
Practice Address - State:OK
Practice Address - Zip Code:74464-4717
Practice Address - Country:US
Practice Address - Phone:919-207-0078
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-01-22
Last Update Date:2021-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor