Provider Demographics
NPI:1629408190
Name:DOULOS COMMUNITY SERVICES
Entity Type:Organization
Organization Name:DOULOS COMMUNITY SERVICES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SECRETARY OFFICE MANAGER
Authorized Official - Prefix:MS
Authorized Official - First Name:CATHERINE
Authorized Official - Middle Name:MARIE
Authorized Official - Last Name:COOK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:909-996-7892
Mailing Address - Street 1:9640 CENTER AVE
Mailing Address - Street 2:SUITE 120
Mailing Address - City:RANCHO CUCAMONGA
Mailing Address - State:CA
Mailing Address - Zip Code:91730-5809
Mailing Address - Country:US
Mailing Address - Phone:909-996-7892
Mailing Address - Fax:
Practice Address - Street 1:9640 CENTER AVE
Practice Address - Street 2:SUITE 120
Practice Address - City:RANCHO CUCAMONGA
Practice Address - State:CA
Practice Address - Zip Code:91730-5809
Practice Address - Country:US
Practice Address - Phone:909-996-7892
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-11-20
Last Update Date:2013-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY12904103TC0700X
CAMFC39894106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Multi-Specialty
No106H00000XBehavioral Health & Social Service ProvidersMarriage & Family TherapistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAOPL129041OtherMEDICARE PTAN