Provider Demographics
NPI:1144252693
Name:SCHICKEDANZ, DAVID I (PHD)
Entity type:Individual
Prefix:DR
First Name:DAVID
Middle Name:I
Last Name:SCHICKEDANZ
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 1:166 FULLER ST
Mailing Address - Street 2:#2
Mailing Address - City:BROOKLINE
Mailing Address - State:MA
Mailing Address - Zip Code:02446-5714
Mailing Address - Country:US
Mailing Address - Phone:617-232-6497
Mailing Address - Fax:978-687-2750
Practice Address - Street 1:166 FULLER ST
Practice Address - Street 2:#2
Practice Address - City:BROOKLINE
Practice Address - State:MA
Practice Address - Zip Code:02446-5714
Practice Address - Country:US
Practice Address - Phone:617-232-6497
Practice Address - Fax:978-687-2750
Is Sole Proprietor?:No
Enumeration Date:2006-07-07
Last Update Date:2013-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA3471103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical