Provider Demographics
NPI:1952693624
Name:PICKETT, GLORIA ANN
Entity Type:Individual
Prefix:MS
First Name:GLORIA
Middle Name:ANN
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 1:19741 RUTHERFORD
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48235
Mailing Address - Country:US
Mailing Address - Phone:313-729-2232
Mailing Address - Fax:313-243-2128
Practice Address - Street 1:19741 RUTHERFORD
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48235
Practice Address - Country:US
Practice Address - Phone:313-729-2232
Practice Address - Fax:313-243-2128
Is Sole Proprietor?:No
Enumeration Date:2011-05-12
Last Update Date:2011-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6401005370101Y00000X, 104100000X, 106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
No104100000XBehavioral Health & Social Service ProvidersSocial Worker
No106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist