Provider Demographics
NPI:1770849960
Name:DOUROUX, NICHOLAS EDWARD SR
Entity Type:Individual
Prefix:
First Name:NICHOLAS
Middle Name:EDWARD
Last Name:DOUROUX
Suffix:SR
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 1:1295 GRAND SUMMIT DR
Mailing Address - Street 2:244
Mailing Address - City:RENO
Mailing Address - State:NV
Mailing Address - Zip Code:89523-2622
Mailing Address - Country:US
Mailing Address - Phone:310-962-4036
Mailing Address - Fax:
Practice Address - Street 1:1295 GRAND SUMMIT DR
Practice Address - Street 2:244
Practice Address - City:RENO
Practice Address - State:NV
Practice Address - Zip Code:89523-2622
Practice Address - Country:US
Practice Address - Phone:310-962-4036
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-04-02
Last Update Date:2012-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV00001283458Medicaid