Provider Demographics
NPI:1033676945
Name:DOUGLAS, MARTINETTE Z
Entity Type:Individual
Prefix:
First Name:MARTINETTE
Middle Name:Z
Last Name:DOUGLAS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:207 CALLE DE PARQUE
Mailing Address - Street 2:APT, SUITE, BLDG. (OPTIONAL)
Mailing Address - City:SAN JUAN
Mailing Address - State:PR
Mailing Address - Zip Code:00907
Mailing Address - Country:US
Mailing Address - Phone:773-669-8168
Mailing Address - Fax:
Practice Address - Street 1:2931 PAYSON HTS APT SUITE
Practice Address - Street 2:
Practice Address - City:QUINCY
Practice Address - State:IL
Practice Address - Zip Code:62305-6429
Practice Address - Country:US
Practice Address - Phone:773-669-8168
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-02-27
Last Update Date:2019-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL180009750101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty