Provider Demographics
NPI:1538772793
Name:DOUSE, PETA-GAY (MED, MSED)
Entity type:Individual
Prefix:MS
First Name:PETA-GAY
Middle Name:
Last Name:DOUSE
Suffix:
Gender:F
Credentials:MED, MSED
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11571 SPRINGFIELD BLVD APT 1
Mailing Address - Street 2:
Mailing Address - City:CAMBRIA HEIGHTS
Mailing Address - State:NY
Mailing Address - Zip Code:11411-1135
Mailing Address - Country:US
Mailing Address - Phone:347-744-3186
Mailing Address - Fax:
Practice Address - Street 1:3961 HILLMAN AVE
Practice Address - Street 2:
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10463-3001
Practice Address - Country:US
Practice Address - Phone:718-796-9200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-08-27
Last Update Date:2020-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY1203052181174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist