Provider Demographics
NPI:1588380364
Name:RENE, DOUDLY (NONE)
Entity type:Individual
Prefix:
First Name:DOUDLY
Middle Name:
Last Name:RENE
Suffix:
Gender:F
Credentials:NONE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:90 CANAL ST
Mailing Address - Street 2:
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02114-2018
Mailing Address - Country:US
Mailing Address - Phone:888-922-2348
Mailing Address - Fax:855-568-2494
Practice Address - Street 1:90 CANAL ST FL 4
Practice Address - Street 2:
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02114-2018
Practice Address - Country:US
Practice Address - Phone:888-922-2843
Practice Address - Fax:855-568-2494
Is Sole Proprietor?:No
Enumeration Date:2022-10-13
Last Update Date:2022-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MABACB846019106S00000X
106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician