Healthcare Provider Details

I. General information

NPI: 1871367821
Provider Name (Legal Business Name): CODY MICHAEL PICKETT LPC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/09/2023
Last Update Date: 11/06/2025
Certification Date: 11/06/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1248 E 17TH ST
IDAHO FALLS ID
83404-6147
US

IV. Provider business mailing address

1248 E 17TH ST
IDAHO FALLS ID
83404-6147
US

V. Phone/Fax

Practice location:
  • Phone: 208-542-1026
  • Fax:
Mailing address:
  • Phone: 208-542-1026
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberLPC-10001
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: