Healthcare Provider Details

I. General information

NPI: 1033103619
Provider Name (Legal Business Name): PAUL DOUGLAS HAUCK PHD.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/09/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

60MDG/SGOHH 101 BODIN CIR
TRAVIS AFB CA
94535
US

IV. Provider business mailing address

5070 ADALIS DR
ELK GROVE CA
95758-6778
US

V. Phone/Fax

Practice location:
  • Phone: 707-423-5174
  • Fax:
Mailing address:
  • Phone: 916-392-9970
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC2200X
TaxonomyClinical Child & Adolescent Psychologist
License Number6689
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: