Provider Demographics
NPI:1841319043
Name:SPECK, DOUGLAS MARR (PHD)
Entity type:Individual
Prefix:DR
First Name:DOUGLAS
Middle Name:MARR
Last Name:SPECK
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 88
Mailing Address - Street 2:
Mailing Address - City:BRADFORD
Mailing Address - State:VT
Mailing Address - Zip Code:05033
Mailing Address - Country:US
Mailing Address - Phone:802-222-9001
Mailing Address - Fax:802-222-9242
Practice Address - Street 1:540 ROUTE 5 SOUTH
Practice Address - Street 2:
Practice Address - City:BRADFORD
Practice Address - State:VT
Practice Address - Zip Code:05033
Practice Address - Country:US
Practice Address - Phone:802-222-9001
Practice Address - Fax:802-222-9242
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT754103TC0700X
NH918103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NH30423048Medicaid
VT1007089Medicaid