Provider Demographics
NPI:1184027401
Name:BRICKLIN-SMALL, DAVID
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:
Last Name:BRICKLIN-SMALL
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:DAVID
Other - Middle Name:MARC
Other - Last Name:SMALL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:340 MAPLE ST
Mailing Address - Street 2:
Mailing Address - City:MARLBOROUGH
Mailing Address - State:MA
Mailing Address - Zip Code:01752-3200
Mailing Address - Country:US
Mailing Address - Phone:541-521-2742
Mailing Address - Fax:
Practice Address - Street 1:147 MILK STREET
Practice Address - Street 2:
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02109-3200
Practice Address - Country:US
Practice Address - Phone:617-654-7300
Practice Address - Fax:716-461-7654
Is Sole Proprietor?:Yes
Enumeration Date:2014-10-01
Last Update Date:2018-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA10819103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Multi-Specialty