Provider Demographics
NPI:1275804304
Name:FREA, WILLIAM DOUGLAS (PHD)
Entity Type:Individual
Prefix:
First Name:WILLIAM
Middle Name:DOUGLAS
Last Name:FREA
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 1:6672 GUNPARK DRIVE
Mailing Address - Street 2:SUITE 100
Mailing Address - City:BOULDER
Mailing Address - State:CO
Mailing Address - Zip Code:80301
Mailing Address - Country:US
Mailing Address - Phone:303-530-4972
Mailing Address - Fax:
Practice Address - Street 1:6672 GUNPARK DRIVE
Practice Address - Street 2:SUITE 100
Practice Address - City:BOULDER
Practice Address - State:CO
Practice Address - Zip Code:80301
Practice Address - Country:US
Practice Address - Phone:303-530-4972
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-01-20
Last Update Date:2014-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
1-07-3520103K00000X
CO3409103TC0700X, 103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst