Provider Demographics
NPI:1285283457
Name:PICKENS, MARY BENNETT
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:BENNETT
Last Name:PICKENS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:933 PARIS AVE STE B
Mailing Address - Street 2:
Mailing Address - City:PORT ROYAL
Mailing Address - State:SC
Mailing Address - Zip Code:29935-2146
Mailing Address - Country:US
Mailing Address - Phone:843-593-0909
Mailing Address - Fax:
Practice Address - Street 1:933 PARIS AVE STE B
Practice Address - Street 2:
Practice Address - City:PORT ROYAL
Practice Address - State:SC
Practice Address - Zip Code:29935-2146
Practice Address - Country:US
Practice Address - Phone:843-593-0909
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-09-10
Last Update Date:2024-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC301100Medicaid