Provider Demographics
NPI:1558378273
Name:BICKNELL, GRAEME CHARLES (PHD)
Entity Type:Individual
Prefix:
First Name:GRAEME
Middle Name:CHARLES
Last Name:BICKNELL
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 1:2716 W PRICE AVE
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33611-3834
Mailing Address - Country:US
Mailing Address - Phone:813-828-6611
Mailing Address - Fax:
Practice Address - Street 1:4815 BAYSHORE BLVD
Practice Address - Street 2:6TH MEDICAL GROUP
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33621
Practice Address - Country:US
Practice Address - Phone:813-827-9870
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMI 34741041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical