Provider Demographics
NPI:1467897413
Name:CACIALLI, DOUGLAS OWEN (PHD)
Entity Type:Individual
Prefix:DR
First Name:DOUGLAS
Middle Name:OWEN
Last Name:CACIALLI
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:PO BOX 5400
Mailing Address - Street 2:
Mailing Address - City:ADELANTO
Mailing Address - State:CA
Mailing Address - Zip Code:92301-5400
Mailing Address - Country:US
Mailing Address - Phone:760-530-5000
Mailing Address - Fax:
Practice Address - Street 1:13777 AIR EXPRESSWAY BLVD
Practice Address - Street 2:
Practice Address - City:VICTORVILLE
Practice Address - State:CA
Practice Address - Zip Code:92394-0510
Practice Address - Country:US
Practice Address - Phone:760-530-5000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-05-03
Last Update Date:2013-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY 25356103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical