MEDICARE: THOMAS D PICTON JR. M DIV

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	106H00000X	Marriage & Family Therapist	499	LA
2	106H00000X	Marriage & Family Therapist	1220	TX

General Provider Information

NPI Number	:	1265633010
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	THOMAS D PICTON JR. M DIV

Provider Business Mailing Address
First Line	:	PO BOX 300246
Second Line	:
City	:	DENVER
State	:	CO
Zip	:	80203
Country	:	US
Telephone Number	:	303-370-0035
Fax Number	:	303-370-0036

Provider Business Practice Location Address
First Line	:	5354 PLANK ROAD
Second Line	:
City	:	BATON ROUGE
State	:	LA
Zip	:	70892-3900
Country	:	US
Telephone Number	:	225-355-3377
Fax Number	:	225-355-6200

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/30/2007
Last Update Date	:	07/08/2007

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