Provider Demographics
NPI:1912677147
Name:PICKRELL, NICOLE LYNN
Entity type:Individual
Prefix:MS
First Name:NICOLE
Middle Name:LYNN
Last Name:PICKRELL
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 1:130 WASHINGTON AVE
Mailing Address - Street 2:
Mailing Address - City:DOWNINGTOWN
Mailing Address - State:PA
Mailing Address - Zip Code:19335-2950
Mailing Address - Country:US
Mailing Address - Phone:941-330-5535
Mailing Address - Fax:
Practice Address - Street 1:46 MYSTERY ROSE LN
Practice Address - Street 2:
Practice Address - City:WEST GROVE
Practice Address - State:PA
Practice Address - Zip Code:19390-8812
Practice Address - Country:US
Practice Address - Phone:610-316-7307
Practice Address - Fax:610-436-1208
Is Sole Proprietor?:No
Enumeration Date:2021-09-19
Last Update Date:2021-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RBT-21-180968106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician