MEDICARE: DR. BRAD SICKENIUS PH.D.

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	103TC0700X	Clinical Psychologist	PSY 16336	CA

General Provider Information

NPI Number	:	1982705638
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. BRAD SICKENIUS PH.D.

Provider Business Mailing Address
First Line	:	2424 DWIGHT WAY STE 8
Second Line	:
City	:	BERKELEY
State	:	CA
Zip	:	94704-2365
Country	:	US
Telephone Number	:	510-435-6600
Fax Number	:	510-588-4444

Provider Business Practice Location Address
First Line	:	2424 DWIGHT WAY STE 8
Second Line	:
City	:	BERKELEY
State	:	CA
Zip	:	94704-2365
Country	:	US
Telephone Number	:	510-435-6600
Fax Number	:	510-588-4444

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

Provider Enumeration Date	:	09/26/2006
Last Update Date	:	07/08/2007

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