Provider Demographics
NPI:1972050268
Name:PICKERING, ANGELA KATHRYN (BCBA)
Entity Type:Individual
Prefix:MRS
First Name:ANGELA
Middle Name:KATHRYN
Last Name:PICKERING
Suffix:
Gender:F
Credentials:BCBA
Other - Prefix:
Other - First Name:ANGELA
Other - Middle Name:KATHRYN
Other - Last Name:JOHNSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1919 SE 36TH AVE
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97214-5184
Mailing Address - Country:US
Mailing Address - Phone:530-209-2944
Mailing Address - Fax:
Practice Address - Street 1:18765 SW BOONES FERRY RD
Practice Address - Street 2:
Practice Address - City:TUALATIN
Practice Address - State:OR
Practice Address - Zip Code:97062-8496
Practice Address - Country:US
Practice Address - Phone:503-233-5405
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-09-05
Last Update Date:2021-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
103K00000X
OR10201681103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR164936Medicaid