Healthcare Provider Details

I. General information

NPI: 1629408190
Provider Name (Legal Business Name): DOULOS COMMUNITY SERVICES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/20/2013
Last Update Date: 11/20/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9640 CENTER AVE SUITE 120
RANCHO CUCAMONGA CA
91730-5809
US

IV. Provider business mailing address

9640 CENTER AVE SUITE 120
RANCHO CUCAMONGA CA
91730-5809
US

V. Phone/Fax

Practice location:
  • Phone: 909-996-7892
  • Fax:
Mailing address:
  • Phone: 909-996-7892
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License NumberPSY12904
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License NumberMFC39894
License Number StateCA

VIII. Authorized Official

Name: MS. CATHERINE MARIE COOK
Title or Position: SECRETARY OFFICE MANAGER
Credential:
Phone: 909-996-7892