Provider Demographics
NPI:1962076927
Name:DOUSE, MOSES JR (CASAC 2-20038)
Entity type:Individual
Prefix:
First Name:MOSES
Middle Name:
Last Name:DOUSE
Suffix:JR
Gender:M
Credentials:CASAC 2-20038
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:882 BERGEN ST
Mailing Address - Street 2:OTP-MMT
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11238
Mailing Address - Country:US
Mailing Address - Phone:718-613-7510
Mailing Address - Fax:718-613-7564
Practice Address - Street 1:882 BERGEN ST
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11238-1123
Practice Address - Country:US
Practice Address - Phone:718-613-7510
Practice Address - Fax:718-613-7564
Is Sole Proprietor?:No
Enumeration Date:2021-05-14
Last Update Date:2021-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY20038101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)