Healthcare Provider Details

I. General information

NPI: 1003753062
Provider Name (Legal Business Name): TYSHON PICKETT
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/29/2026
Last Update Date: 04/29/2026
Certification Date: 04/29/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6826 S MICHIGAN AVE
CHICAGO IL
60637-3908
US

IV. Provider business mailing address

6826 S MICHIGAN AVE
CHICAGO IL
60637-3908
US

V. Phone/Fax

Practice location:
  • Phone: 312-446-1507
  • Fax: 312-446-1507
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: