Provider Demographics
NPI:1063016897
Name:DOUGLAS, SUSAN GAIL
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:GAIL
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 1:3903 HILE RD
Mailing Address - Street 2:
Mailing Address - City:STOW
Mailing Address - State:OH
Mailing Address - Zip Code:44224-4230
Mailing Address - Country:US
Mailing Address - Phone:330-571-1389
Mailing Address - Fax:234-208-8239
Practice Address - Street 1:3903 HILE RD
Practice Address - Street 2:
Practice Address - City:STOW
Practice Address - State:OH
Practice Address - Zip Code:44224-4230
Practice Address - Country:US
Practice Address - Phone:330-571-1389
Practice Address - Fax:234-208-8239
Is Sole Proprietor?:Yes
Enumeration Date:2020-11-23
Last Update Date:2020-11-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant