Provider Demographics
NPI:1063180511
Name:DOULIN, IVY
Entity type:Individual
Prefix:
First Name:IVY
Middle Name:
Last Name:DOULIN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 760
Mailing Address - Street 2:
Mailing Address - City:CORNWALL
Mailing Address - State:NY
Mailing Address - Zip Code:12518-0760
Mailing Address - Country:US
Mailing Address - Phone:845-275-2541
Mailing Address - Fax:
Practice Address - Street 1:118 RIVER RD STE 14
Practice Address - Street 2:
Practice Address - City:HARRIMAN
Practice Address - State:NY
Practice Address - Zip Code:10926-3040
Practice Address - Country:US
Practice Address - Phone:520-884-5863
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-08-31
Last Update Date:2021-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYRBT-21-180538106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician