Provider Demographics
NPI:1194866137
Name:DORET, WENDY BARBARA (PHD)
Entity Type:Individual
Prefix:DR
First Name:WENDY
Middle Name:BARBARA
Last Name:DORET
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:49 FAIRFIELD DR
Mailing Address - Street 2:
Mailing Address - City:DIX HILLS
Mailing Address - State:NY
Mailing Address - Zip Code:11746-7162
Mailing Address - Country:US
Mailing Address - Phone:631-243-6528
Mailing Address - Fax:631-243-6387
Practice Address - Street 1:49 FAIRFIELD DR
Practice Address - Street 2:
Practice Address - City:DIX HILLS
Practice Address - State:NY
Practice Address - Zip Code:11746-7162
Practice Address - Country:US
Practice Address - Phone:631-243-6528
Practice Address - Fax:631-243-6387
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY6257103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00747695Medicaid
NYV23431Medicare ID - Type Unspecified