Provider Demographics
NPI:1912544925
Name:PICKETT, COURTLAND ALEXANDER VANSANT (NCC, LPC/MHSP TEMP)
Entity Type:Individual
Prefix:
First Name:COURTLAND
Middle Name:ALEXANDER VANSANT
Last Name:PICKETT
Suffix:
Gender:M
Credentials:NCC, LPC/MHSP TEMP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2298 S GERMANTOWN RD
Mailing Address - Street 2:
Mailing Address - City:GERMANTOWN
Mailing Address - State:TN
Mailing Address - Zip Code:38138-5962
Mailing Address - Country:US
Mailing Address - Phone:901-481-9877
Mailing Address - Fax:
Practice Address - Street 1:2298 S GERMANTOWN RD
Practice Address - Street 2:
Practice Address - City:GERMANTOWN
Practice Address - State:TN
Practice Address - Zip Code:38138-5962
Practice Address - Country:US
Practice Address - Phone:901-481-9877
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-12-09
Last Update Date:2019-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101Y00000X
706951101YM0800X
TN4268101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101Y00000XBehavioral Health & Social Service ProvidersCounselor
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health