Provider Demographics
NPI:1598641342
Name:PICKERING, MIKE (LADC-1)
Entity type:Individual
Prefix:
First Name:MIKE
Middle Name:
Last Name:PICKERING
Suffix:
Gender:M
Credentials:LADC-1
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:482 SOUTHBRIDGE STREET
Mailing Address - Street 2:BOX NUMBER 356
Mailing Address - City:AUBURN
Mailing Address - State:MA
Mailing Address - Zip Code:01501
Mailing Address - Country:US
Mailing Address - Phone:774-239-9961
Mailing Address - Fax:
Practice Address - Street 1:412 HARDING ST # 1
Practice Address - Street 2:
Practice Address - City:WORCESTER
Practice Address - State:MA
Practice Address - Zip Code:01610-1807
Practice Address - Country:US
Practice Address - Phone:774-239-9961
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-08-14
Last Update Date:2025-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA24729101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)