Provider Demographics
NPI:1255176764
Name:PICKETT, TYLER KAMMERON
Entity type:Individual
Prefix:
First Name:TYLER
Middle Name:KAMMERON
Last Name:PICKETT
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2636 SWEET MAGNOLIA PL
Mailing Address - Street 2:
Mailing Address - City:OVIEDO
Mailing Address - State:FL
Mailing Address - Zip Code:32765-3410
Mailing Address - Country:US
Mailing Address - Phone:415-866-7179
Mailing Address - Fax:
Practice Address - Street 1:400 MAITLAND AVE
Practice Address - Street 2:
Practice Address - City:ALTAMONTE SPRINGS
Practice Address - State:FL
Practice Address - Zip Code:32701-5419
Practice Address - Country:US
Practice Address - Phone:407-831-2991
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-06-26
Last Update Date:2024-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLIMH26082101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health