Basic Information
| Provider Information | |||||||||
| NPI: | 1316051774 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | HENNING | ||||||||
| FirstName: | DOUGLAS | ||||||||
| MiddleName: | DAYNE | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | PHD. PSY | ||||||||
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| Mailing Information | |||||||||
| Address1: | 220 RUSKIN DR | ||||||||
| Address2: | |||||||||
| City: | COLORADO SPRINGS | ||||||||
| State: | CO | ||||||||
| PostalCode: | 80910 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7195726100 | ||||||||
| FaxNumber: | 7195726199 | ||||||||
| Practice Location | |||||||||
| Address1: | 2864 S CIRCLE DRIVE | ||||||||
| Address2: | SUITE 600 | ||||||||
| City: | COLORADO SPRINGS | ||||||||
| State: | CO | ||||||||
| PostalCode: | 80906 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7193144260 | ||||||||
| FaxNumber: | 7192646616 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/19/2006 | ||||||||
| LastUpdateDate: | 08/03/2010 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103T00000X | R0435 | MO | N | Behavioral Health & Social Service Providers | Psychologist | 103T00000X | 0880 | KS | N | Behavioral Health & Social Service Providers | Psychologist | 103T00000X | PSY-3398 | CO | Y | Behavioral Health & Social Service Providers | Psychologist | 103T00000X | 1285 | WA | N | Behavioral Health & Social Service Providers | Psychologist | 103T00000X | PRY 0435 | MO | N | Behavioral Health & Social Service Providers | Psychologist |
ID Information
| ID | Type | State | Issuer | Description | 494788003 | 05 | MO | MEDICAID | 100354730A | 05 | KS | MEDICAID |