Provider Demographics
NPI:1801292388
Name:PICKETT, CASSANDRA
Entity type:Individual
Prefix:
First Name:CASSANDRA
Middle Name:
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 1:50 E 750 N
Mailing Address - Street 2:17
Mailing Address - City:VERNAL
Mailing Address - State:UT
Mailing Address - Zip Code:84078-3767
Mailing Address - Country:US
Mailing Address - Phone:801-450-5419
Mailing Address - Fax:
Practice Address - Street 1:1293 W HIGHWAY 40
Practice Address - Street 2:
Practice Address - City:VERNAL
Practice Address - State:UT
Practice Address - Zip Code:84078-2923
Practice Address - Country:US
Practice Address - Phone:801-450-5419
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-11-11
Last Update Date:2014-11-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT8094968-3902106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist