Provider Demographics
NPI:1902882731
Name:DEVILLE, DOUGLAS M (PSYD)
Entity Type:Individual
Prefix:DR
First Name:DOUGLAS
Middle Name:M
Last Name:DEVILLE
Suffix:
Gender:M
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:729 BOYLSTON ST
Mailing Address - Street 2:4TH FLOOR
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02116-2639
Mailing Address - Country:US
Mailing Address - Phone:617-262-7771
Mailing Address - Fax:617-262-7790
Practice Address - Street 1:729 BOYLSTON ST
Practice Address - Street 2:4TH FLOOR
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02116-2639
Practice Address - Country:US
Practice Address - Phone:617-262-7771
Practice Address - Fax:617-262-7790
Is Sole Proprietor?:Yes
Enumeration Date:2005-12-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA6011103TC0700X
NH600103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MADEW04804Medicaid
NH80001996Medicaid
MAR45429Medicare UPIN
MADEW04804Medicaid
MARE1996Medicare ID - Type Unspecified