Provider Demographics
NPI:1477924462
Name:MCDOUGALL, AMY (MS)
Entity Type:Individual
Prefix:
First Name:AMY
Middle Name:
Last Name:MCDOUGALL
Suffix:
Gender:F
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:24 BUNNY DR
Mailing Address - Street 2:
Mailing Address - City:FULTON
Mailing Address - State:NY
Mailing Address - Zip Code:13069-4829
Mailing Address - Country:US
Mailing Address - Phone:315-402-6874
Mailing Address - Fax:
Practice Address - Street 1:1045 JAMES ST
Practice Address - Street 2:
Practice Address - City:SYRACUSE
Practice Address - State:NY
Practice Address - Zip Code:13203-2730
Practice Address - Country:US
Practice Address - Phone:315-425-1004
Practice Address - Fax:315-422-4855
Is Sole Proprietor?:No
Enumeration Date:2015-10-15
Last Update Date:2015-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY1754892OtherPERMANENT TEACHER CERTIFICATE