Provider Demographics
NPI:1700939089
Name:DOUGALL, CORNELIA REID (PSYD)
Entity type:Individual
Prefix:DR
First Name:CORNELIA
Middle Name:REID
Last Name:DOUGALL
Suffix:
Gender:F
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:PO BOX 28
Mailing Address - Street 2:
Mailing Address - City:MARION
Mailing Address - State:MA
Mailing Address - Zip Code:02738-0001
Mailing Address - Country:US
Mailing Address - Phone:508-748-2007
Mailing Address - Fax:508-748-2077
Practice Address - Street 1:345 FRONT ST
Practice Address - Street 2:
Practice Address - City:MARION
Practice Address - State:MA
Practice Address - Zip Code:02738-1537
Practice Address - Country:US
Practice Address - Phone:508-748-2007
Practice Address - Fax:508-748-2077
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-19
Last Update Date:2007-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA8749103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical