Provider Demographics
NPI:1316286800
Name:DUFORT, DAWSON D (PHD)
Entity type:Individual
Prefix:DR
First Name:DAWSON
Middle Name:D
Last Name:DUFORT
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3315 9TH ST APT 2R
Mailing Address - Street 2:
Mailing Address - City:LONG ISLAND CITY
Mailing Address - State:NY
Mailing Address - Zip Code:11106-4900
Mailing Address - Country:US
Mailing Address - Phone:347-880-2150
Mailing Address - Fax:
Practice Address - Street 1:256 WOODWARD AVE
Practice Address - Street 2:
Practice Address - City:STATEN ISLAND
Practice Address - State:NY
Practice Address - Zip Code:10314-4237
Practice Address - Country:US
Practice Address - Phone:646-807-8325
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-02-04
Last Update Date:2013-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY68P86949103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical