Healthcare Provider Details

I. General information

NPI: 1477335404
Provider Name (Legal Business Name): RORY DOUGALL LSW, ADDC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/16/2023
Last Update Date: 10/16/2023
Certification Date: 10/16/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1975 30TH ST APT 114
BOULDER CO
80301-3067
US

IV. Provider business mailing address

1975 30TH ST APT 114
BOULDER CO
80301-3067
US

V. Phone/Fax

Practice location:
  • Phone: 203-993-5709
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License NumberLSW.0009924738
License Number StateCO

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: