Basic Information
| Provider Information | |||||||||
| NPI: | 1063687168 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | PICKENS | ||||||||
| FirstName: | ELAINE | ||||||||
| MiddleName: | K | ||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | COTA/L | ||||||||
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| Mailing Information | |||||||||
| Address1: | 300 N ALGONQUIN AVE | ||||||||
| Address2: | |||||||||
| City: | COLUMBUS | ||||||||
| State: | OH | ||||||||
| PostalCode: | 432042033 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6142790690 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 170 MILL ST | ||||||||
| Address2: | |||||||||
| City: | GAHANNA | ||||||||
| State: | OH | ||||||||
| PostalCode: | 432303036 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6144145437 | ||||||||
| FaxNumber: | 6144140280 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/29/2008 | ||||||||
| LastUpdateDate: | 04/29/2008 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X | 391 | OH | Y | Other Service Providers | Specialist |
No ID Information.