Healthcare Provider Details

I. General information

NPI: 1649128257
Provider Name (Legal Business Name): STAN PICKETT JR.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/19/2026
Last Update Date: 03/19/2026
Certification Date: 03/19/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1337 GUSDORF RD STE G
TAOS NM
87571-6297
US

IV. Provider business mailing address

513 ZIA ST
TAOS NM
87571-5137
US

V. Phone/Fax

Practice location:
  • Phone: 575-758-4337
  • Fax:
Mailing address:
  • Phone: 314-369-5085
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2355S0801X
TaxonomySpeech-Language Assistant
License NumberSAH-2026-0017
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: