Provider Demographics
NPI:1649719840
Name:PICKETT, LINLEY (PROVIDER)
Entity type:Individual
Prefix:
First Name:LINLEY
Middle Name:
Last Name:PICKETT
Suffix:
Gender:F
Credentials:PROVIDER
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1143 STEEPLE CHASE CIR
Mailing Address - Street 2:
Mailing Address - City:TOLEDO
Mailing Address - State:OH
Mailing Address - Zip Code:43615-4372
Mailing Address - Country:US
Mailing Address - Phone:419-973-8491
Mailing Address - Fax:
Practice Address - Street 1:1143 STEEPLE CHASE CIR
Practice Address - Street 2:
Practice Address - City:TOLEDO
Practice Address - State:OH
Practice Address - Zip Code:43615-4372
Practice Address - Country:US
Practice Address - Phone:419-973-8491
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-02-21
Last Update Date:2017-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH101YA0400X, 374U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0172198Medicaid