Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 102L00000X | Psychologist | 1263 | NH |
Y | 103T00000X | Psychologist | 1263 | NH |
N | 103G00000X | Clinical Psychologist | 9891 | MA |
N | 103TC0700X | Clinical Psychologist | 9891 | MA |
NPI | 1003166323 |
---|---|
Provider Name | Brad Spickard |
First Address | Newton, MA 02458-1604 |
Second Address | Newton, MA 02458-1604 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 13/09/2012 |
Last Update Date | 13/08/2014 |