=====================================================
General NPI Number Information
=====================================================
NPI Number | 1033149141
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | WILLIAM DOUGLAS CANTERBURY-COUNTS PH.D.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/04/2006
-----------------------------------------------------
Last Update Date | 06/13/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 8445 CAMPBELL AVE
-----------------------------------------------------
City | SEBASTIAN
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32958-4409
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 772-532-5769
-----------------------------------------------------
Fax | 866-806-5244
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 8445 CAMPBELL AVE
-----------------------------------------------------
City | SEBASTIAN
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32958-4409
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 772-532-5769
-----------------------------------------------------
Fax | 866-806-5244
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 103G00000X
-----------------------------------------------------
Taxonomy Name | Clinical Neuropsychologist
-----------------------------------------------------
License Number | PY4461
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 103T00000X
-----------------------------------------------------
Taxonomy Name | Psychologist
-----------------------------------------------------
License Number | PY4461
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------