Provider Demographics
NPI:1811530546
Name:PICKETT, SHAUNDRA NICOLE
Entity type:Individual
Prefix:
First Name:SHAUNDRA
Middle Name:NICOLE
Last Name:PICKETT
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 1:169 LAURELHURST AVE
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:SC
Mailing Address - Zip Code:29210-3825
Mailing Address - Country:US
Mailing Address - Phone:803-733-5969
Mailing Address - Fax:
Practice Address - Street 1:2117 GERVAIS ST
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29204-1805
Practice Address - Country:US
Practice Address - Phone:803-744-0540
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-10-25
Last Update Date:2023-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC8504101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional