Basic Information
| Provider Information | |||||||||
| NPI: | 1790260073 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | PICKETT | ||||||||
| FirstName: | RYAN | ||||||||
| MiddleName: | A | ||||||||
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| Credential: | PLPC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 118 N 2ND ST STE 200 | ||||||||
| Address2: | |||||||||
| City: | SAINT CHARLES | ||||||||
| State: | MO | ||||||||
| PostalCode: | 633012894 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6362241210 | ||||||||
| FaxNumber: | 6369460991 | ||||||||
| Practice Location | |||||||||
| Address1: | 4355 PARIS GRAVEL RD | ||||||||
| Address2: | |||||||||
| City: | HANNIBAL | ||||||||
| State: | MO | ||||||||
| PostalCode: | 634016017 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5732483811 | ||||||||
| FaxNumber: | 5732483080 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/02/2018 | ||||||||
| LastUpdateDate: | 10/02/2018 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YP2500X | 2018011698 | MO | Y | Behavioral Health & Social Service Providers | Counselor | Professional |
No ID Information.