Provider Demographics
NPI:1649036260
Name:PICKETT, ADAMARISE ANGEL GRACE
Entity type:Individual
Prefix:
First Name:ADAMARISE
Middle Name:ANGEL GRACE
Last Name:PICKETT
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 1:2473 SW GALIANO RD
Mailing Address - Street 2:
Mailing Address - City:PORT ST LUCIE
Mailing Address - State:FL
Mailing Address - Zip Code:34987-2061
Mailing Address - Country:US
Mailing Address - Phone:772-985-6310
Mailing Address - Fax:
Practice Address - Street 1:2473 SW GALIANO RD
Practice Address - Street 2:
Practice Address - City:PORT ST LUCIE
Practice Address - State:FL
Practice Address - Zip Code:34987-2061
Practice Address - Country:US
Practice Address - Phone:772-985-6310
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-02-21
Last Update Date:2024-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical