Healthcare Provider Details

I. General information

NPI: 1790862092
Provider Name (Legal Business Name): GERALD BRICKELL
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/01/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

64 INDUSTRIAL PARK RD
PLYMOUTH MA
02360-4881
US

IV. Provider business mailing address

35 PARK ST 2ND FL
STOUGHTON MA
02072-2913
US

V. Phone/Fax

Practice location:
  • Phone: 508-830-1630
  • Fax:
Mailing address:
  • Phone: 781-344-2220
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number203421
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: