Provider Demographics
NPI:1033226923
Name:DOUGLAS, MARK A (CTRS)
Entity Type:Individual
Prefix:MR
First Name:MARK
Middle Name:A
Last Name:DOUGLAS
Suffix:
Gender:M
Credentials:CTRS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1500 S TAYLOR ST
Mailing Address - Street 2:
Mailing Address - City:LITTLE ROCK
Mailing Address - State:AR
Mailing Address - Zip Code:72204-2663
Mailing Address - Country:US
Mailing Address - Phone:501-257-3285
Mailing Address - Fax:
Practice Address - Street 1:2200 FORT ROOTS DR
Practice Address - Street 2:
Practice Address - City:NORTH LITTLE ROCK
Practice Address - State:AR
Practice Address - Zip Code:72114-1709
Practice Address - Country:US
Practice Address - Phone:501-257-3285
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR26219225800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225800000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRecreation Therapist