MEDICARE: DOMINIQUE NIASIA PICKETT MA, ATR-P, LAAT

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	221700000X	Art Therapist	6LA00002100	NJ

General Provider Information

NPI Number	:	1609672781
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DOMINIQUE NIASIA PICKETT MA, ATR-P, LAAT

Provider Business Mailing Address
First Line	:	1114 W 5TH ST
Second Line	:
City	:	PLAINFIELD
State	:	NJ
Zip	:	07063-1424
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	1114 W 5TH ST
Second Line	:
City	:	PLAINFIELD
State	:	NJ
Zip	:	07063-1424
Country	:	US
Telephone Number	:	908-391-8710
Fax Number	:

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

Provider Enumeration Date	:	02/20/2025
Last Update Date	:	02/20/2025

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