Healthcare Provider Details

I. General information

NPI: 1871652248
Provider Name (Legal Business Name): DOUGLAS JOHN SCAMBLER PH.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/08/2006
Last Update Date: 09/10/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

507 S 4TH ST SUITE A
LARAMIE WY
82070-3753
US

IV. Provider business mailing address

507 S 4TH ST SUITE A
LARAMIE WY
82070-3753
US

V. Phone/Fax

Practice location:
  • Phone: 307-460-0120
  • Fax: 307-742-4089
Mailing address:
  • Phone: 307-460-0120
  • Fax: 307-742-4089

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number965
License Number StateOK
# 2
Primary TaxonomyN
Taxonomy Code103TC2200X
TaxonomyClinical Child & Adolescent Psychologist
License Number965
License Number StateOK
# 3
Primary TaxonomyN
Taxonomy Code103TM1800X
TaxonomyIntellectual & Developmental Disabilities Psychologist
License Number965
License Number StateOK
# 4
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number448
License Number StateWY
# 5
Primary TaxonomyN
Taxonomy Code103TC2200X
TaxonomyClinical Child & Adolescent Psychologist
License Number448
License Number StateWY
# 6
Primary TaxonomyN
Taxonomy Code103TB0200X
TaxonomyCognitive & Behavioral Psychologist
License Number448
License Number StateWY
# 7
Primary TaxonomyN
Taxonomy Code103TM1800X
TaxonomyIntellectual & Developmental Disabilities Psychologist
License Number448
License Number StateWY
# 8
Primary TaxonomyN
Taxonomy Code103TP2701X
TaxonomyGroup Psychotherapy Psychologist
License Number448
License Number StateWY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: