Healthcare Provider Details

I. General information

NPI: 1255176764
Provider Name (Legal Business Name): TYLER KAMMERON PICKETT
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/26/2024
Last Update Date: 06/26/2024
Certification Date: 06/26/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

400 MAITLAND AVE
ALTAMONTE SPRINGS FL
32701-5419
US

IV. Provider business mailing address

2636 SWEET MAGNOLIA PL
OVIEDO FL
32765-3410
US

V. Phone/Fax

Practice location:
  • Phone: 407-831-2991
  • Fax:
Mailing address:
  • Phone: 415-866-7179
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberIMH26082
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: