=====================================================
General NPI Number Information
=====================================================
NPI Number | 1649128257
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | STAN PICKETT JR.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/19/2026
-----------------------------------------------------
Last Update Date | 03/19/2026
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1337 GUSDORF RD STE G
-----------------------------------------------------
City | TAOS
-----------------------------------------------------
State | NM
-----------------------------------------------------
Zip | 87571-6297
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 575-758-4337
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 513 ZIA ST
-----------------------------------------------------
City | TAOS
-----------------------------------------------------
State | NM
-----------------------------------------------------
Zip | 87571-5137
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 314-369-5085
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2355S0801X
-----------------------------------------------------
Taxonomy Name | Speech-Language Assistant
-----------------------------------------------------
License Number | SAH-2026-0017
-----------------------------------------------------
License Number State | NM
-----------------------------------------------------