Healthcare Provider Details

I. General information

NPI: 1275804304
Provider Name (Legal Business Name): WILLIAM DOUGLAS FREA PH.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/20/2012
Last Update Date: 10/08/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6672 GUNPARK DRIVE SUITE 100
BOULDER CO
80301
US

IV. Provider business mailing address

6672 GUNPARK DRIVE SUITE 100
BOULDER CO
80301
US

V. Phone/Fax

Practice location:
  • Phone: 303-530-4972
  • Fax:
Mailing address:
  • Phone: 303-530-4972
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number1-07-3520
License Number State
# 2
Primary TaxonomyN
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number3409
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: