Provider Demographics
NPI:1578630943
Name:PICKETT, DEANNA NICOLE (LPC, MA)
Entity type:Individual
Prefix:
First Name:DEANNA
Middle Name:NICOLE
Last Name:PICKETT
Suffix:
Gender:
Credentials:LPC, MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6800 SW 105TH AVE STE 101
Mailing Address - Street 2:
Mailing Address - City:BEAVERTON
Mailing Address - State:OR
Mailing Address - Zip Code:97008-5488
Mailing Address - Country:US
Mailing Address - Phone:971-200-1966
Mailing Address - Fax:971-754-4141
Practice Address - Street 1:6800 SW 105TH AVE STE 101
Practice Address - Street 2:
Practice Address - City:BEAVERTON
Practice Address - State:OR
Practice Address - Zip Code:97008-5488
Practice Address - Country:US
Practice Address - Phone:971-200-1966
Practice Address - Fax:971-754-4141
Is Sole Proprietor?:No
Enumeration Date:2006-11-29
Last Update Date:2025-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YM0800X
ORC2289101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR128715Medicaid