Provider Demographics
NPI:1316633126
Name:PICKENS, MONIQUE A (CLC)
Entity type:Individual
Prefix:MS
First Name:MONIQUE
Middle Name:A
Last Name:PICKENS
Suffix:
Gender:F
Credentials:CLC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1137 2ND ST STE 211
Mailing Address - Street 2:
Mailing Address - City:SANTA MONICA
Mailing Address - State:CA
Mailing Address - Zip Code:90403-5078
Mailing Address - Country:US
Mailing Address - Phone:310-995-2662
Mailing Address - Fax:
Practice Address - Street 1:1137 2ND ST STE 211
Practice Address - Street 2:
Practice Address - City:SANTA MONICA
Practice Address - State:CA
Practice Address - Zip Code:90403-5078
Practice Address - Country:US
Practice Address - Phone:310-995-2662
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-04-14
Last Update Date:2023-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA225700000X, 374J00000X, 174N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174N00000XOther Service ProvidersLactation Consultant, Non-RNGroup - Single Specialty
No225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist
No374J00000XNursing Service Related ProvidersDoula