Provider Demographics
NPI:1194786269
Name:PICKENS, DESTRE WADE (ATC)
Entity type:Individual
Prefix:MR
First Name:DESTRE
Middle Name:WADE
Last Name:PICKENS
Suffix:
Gender:M
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:900 N GRAND AVE
Mailing Address - Street 2:SUITE 6A
Mailing Address - City:SHERMAN
Mailing Address - State:TX
Mailing Address - Zip Code:75090-4440
Mailing Address - Country:US
Mailing Address - Phone:903-813-2514
Mailing Address - Fax:
Practice Address - Street 1:900 N GRAND AVE
Practice Address - Street 2:SUITE 6A
Practice Address - City:SHERMAN
Practice Address - State:TX
Practice Address - Zip Code:75090-4440
Practice Address - Country:US
Practice Address - Phone:903-813-2514
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-03-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXAT31852255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer