Basic Information
| Provider Information | |||||||||
| NPI: | 1447267067 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | PICKELL | ||||||||
| FirstName: | BRIAN | ||||||||
| MiddleName: | |||||||||
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| Credential: | PSY.D | ||||||||
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| Mailing Information | |||||||||
| Address1: | 280 CHESTNUT ST FL 2 | ||||||||
| Address2: | |||||||||
| City: | SPRINGFIELD | ||||||||
| State: | MA | ||||||||
| PostalCode: | 011991001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4137949999 | ||||||||
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| Practice Location | |||||||||
| Address1: | 42 WRIGHT ST | ||||||||
| Address2: | |||||||||
| City: | PALMER | ||||||||
| State: | MA | ||||||||
| PostalCode: | 010691156 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4133705285 | ||||||||
| FaxNumber: | 4133705384 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/03/2006 | ||||||||
| LastUpdateDate: | 02/14/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 02/14/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 104100000X | 6191 | MA | N | Behavioral Health & Social Service Providers | Social Worker | 103T00000X | 6191 | MA | Y | Behavioral Health & Social Service Providers | Psychologist |
ID Information
| ID | Type | State | Issuer | Description | 0522058 | 05 | MA | MEDICAID |