MEDICARE: BRAD SPICKARD PHD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	103T00000X	Psychologist	1263	NH
2	103TC0700X	Clinical Psychologist	9891	MA

General Provider Information

NPI Number	:	1003166323
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	BRAD SPICKARD PHD

Provider Business Mailing Address
First Line	:	49B CARLETON ST
Second Line	:
City	:	NEWTON
State	:	MA
Zip	:	02458-1604
Country	:	US
Telephone Number	:	617-207-4124
Fax Number	:

Provider Business Practice Location Address
First Line	:	49B CARLETON ST
Second Line	:
City	:	NEWTON
State	:	MA
Zip	:	02458-1604
Country	:	US
Telephone Number	:	617-207-4124
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/13/2012
Last Update Date	:	08/13/2014

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Directions to “ BRAD SPICKARD PHD” Practice Location

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