Provider Demographics
NPI:1700667714
Name:PICKENS, MICHELLE LEWIS
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:LEWIS
Last Name:PICKENS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:130 VICTORIA CIR
Mailing Address - Street 2:
Mailing Address - City:ANDERSON
Mailing Address - State:SC
Mailing Address - Zip Code:29621-4075
Mailing Address - Country:US
Mailing Address - Phone:864-979-3370
Mailing Address - Fax:
Practice Address - Street 1:1209 N FANT ST
Practice Address - Street 2:
Practice Address - City:ANDERSON
Practice Address - State:SC
Practice Address - Zip Code:29621-4821
Practice Address - Country:US
Practice Address - Phone:864-353-3384
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-10-06
Last Update Date:2023-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC9212101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional