Provider Demographics
NPI:1518396886
Name:MACDOUGALL, THOMAS RICHARD (MSED, NCSP)
Entity Type:Individual
Prefix:
First Name:THOMAS
Middle Name:RICHARD
Last Name:MACDOUGALL
Suffix:
Gender:M
Credentials:MSED, NCSP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:776 EVES DR APT 5C
Mailing Address - Street 2:
Mailing Address - City:HILLSBOROUGH
Mailing Address - State:NJ
Mailing Address - Zip Code:08844-4968
Mailing Address - Country:US
Mailing Address - Phone:631-252-5129
Mailing Address - Fax:
Practice Address - Street 1:329 NORWAY AVE
Practice Address - Street 2:
Practice Address - City:STATEN ISLAND
Practice Address - State:NY
Practice Address - Zip Code:10305-3524
Practice Address - Country:US
Practice Address - Phone:718-987-9400
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-11-06
Last Update Date:2013-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY2549431174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist