Provider Demographics
NPI:1255385209
Name:PICOU, MARK DAVID (PT)
Entity type:Individual
Prefix:MR
First Name:MARK
Middle Name:DAVID
Last Name:PICOU
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3909 NE STALLINGS DR
Mailing Address - Street 2:
Mailing Address - City:NACOGDOCHES
Mailing Address - State:TX
Mailing Address - Zip Code:75965-2169
Mailing Address - Country:US
Mailing Address - Phone:936-564-7780
Mailing Address - Fax:936-564-0745
Practice Address - Street 1:3909 NE STALLINGS DR
Practice Address - Street 2:
Practice Address - City:NACOGDOCHES
Practice Address - State:TX
Practice Address - Zip Code:75965
Practice Address - Country:US
Practice Address - Phone:936-564-7780
Practice Address - Fax:936-564-0745
Is Sole Proprietor?:No
Enumeration Date:2006-05-22
Last Update Date:2011-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1071991225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX1071991OtherTX BOARD OF PT EXAMINERS
TX021252401Medicaid
TX1071991OtherTX BOARD OF PT EXAMINERS