Healthcare Provider Details

I. General information

NPI: 1205749967
Provider Name (Legal Business Name): MICKENSON ST-PIERRE
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/24/2026
Last Update Date: 09/24/2026
Certification Date: 09/24/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5 NATALIE WAY
PLYMOUTH MA
02360-3557
US

IV. Provider business mailing address

738 PLAIN ST APT 9
MARSHFIELD MA
02050-2101
US

V. Phone/Fax

Practice location:
  • Phone: 774-351-0299
  • Fax:
Mailing address:
  • Phone: 857-303-6319
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License NumberRBT-25-487504
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: