Provider Demographics
NPI:1003166323
Name:SPICKARD, BRAD (PHD)
Entity Type:Individual
Prefix:
First Name:BRAD
Middle Name:
Last Name:SPICKARD
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:49B CARLETON ST
Mailing Address - Street 2:
Mailing Address - City:NEWTON
Mailing Address - State:MA
Mailing Address - Zip Code:02458-1604
Mailing Address - Country:US
Mailing Address - Phone:617-207-4124
Mailing Address - Fax:
Practice Address - Street 1:49B CARLETON ST
Practice Address - Street 2:
Practice Address - City:NEWTON
Practice Address - State:MA
Practice Address - Zip Code:02458-1604
Practice Address - Country:US
Practice Address - Phone:617-207-4124
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-09-13
Last Update Date:2014-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NH1263103T00000X
MA9891103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical