Healthcare Provider Details

I. General information

NPI: 1699190074
Provider Name (Legal Business Name): CYNTHIA PICKENS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/21/2014
Last Update Date: 12/13/2022
Certification Date: 12/13/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

777 CASINO AVE
THACKERVILLE OK
73459-9774
US

IV. Provider business mailing address

1300 HOPPE BLVD STE 1
ADA OK
74820-2319
US

V. Phone/Fax

Practice location:
  • Phone: 580-272-5170
  • Fax:
Mailing address:
  • Phone: 580-436-7269
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: