Basic Information
| Provider Information | |||||||||
| NPI: | 1982201125 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DOUVILLE | ||||||||
| FirstName: | KENDALL | ||||||||
| MiddleName: | |||||||||
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| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | SPERA | ||||||||
| OtherFirstName: | KENDALL | ||||||||
| OtherMiddleName: | |||||||||
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| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 1000 JEFFERSON ST STE 2C | ||||||||
| Address2: | |||||||||
| City: | LYNCHBURG | ||||||||
| State: | VA | ||||||||
| PostalCode: | 245041724 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5402176461 | ||||||||
| FaxNumber: | 6178070958 | ||||||||
| Practice Location | |||||||||
| Address1: | 5410 LYNX LN STE 285 | ||||||||
| Address2: | |||||||||
| City: | COLUMBIA | ||||||||
| State: | MD | ||||||||
| PostalCode: | 210442483 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 1074032404 | ||||||||
| FaxNumber: | 6178070958 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/01/2020 | ||||||||
| LastUpdateDate: | 10/01/2020 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
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| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
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| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| NPICertificationDate: | 10/01/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | 21580 | MD | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
No ID Information.