Healthcare Provider Details

I. General information

NPI: 1700378361
Provider Name (Legal Business Name): GREGORY PICKUS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/30/2018
Last Update Date: 01/30/2025
Certification Date: 01/30/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7305 N MILITARY TRL
RIVIERA BEACH FL
33410-7417
US

IV. Provider business mailing address

265 COURTNEY LAKES CIR APT 103
WEST PALM BEACH FL
33401-2392
US

V. Phone/Fax

Practice location:
  • Phone: 561-422-8262
  • Fax:
Mailing address:
  • Phone: 207-233-7437
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License NumberPSY-005746
License Number StateAZ
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: