Provider Demographics
NPI:1639754138
Name:DOULTON, FRED
Entity Type:Individual
Prefix:
First Name:FRED
Middle Name:
Last Name:DOULTON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:102 GLEN COVE DR
Mailing Address - Street 2:
Mailing Address - City:GLEN HEAD
Mailing Address - State:NY
Mailing Address - Zip Code:11545-1715
Mailing Address - Country:US
Mailing Address - Phone:516-551-5493
Mailing Address - Fax:
Practice Address - Street 1:102 GLEN COVE DR
Practice Address - Street 2:
Practice Address - City:GLEN HEAD
Practice Address - State:NY
Practice Address - Zip Code:11545-1715
Practice Address - Country:US
Practice Address - Phone:516-551-5493
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-03-16
Last Update Date:2021-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY011164101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health