Provider Demographics
NPI:1093214264
Name:DOUGLASS, AMANDA ELIZABETH (DSP,CRMA)
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:ELIZABETH
Last Name:DOUGLASS
Suffix:
Gender:F
Credentials:DSP,CRMA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:131 OAKLAND RD
Mailing Address - Street 2:
Mailing Address - City:FAIRFIELD
Mailing Address - State:ME
Mailing Address - Zip Code:04937-3229
Mailing Address - Country:US
Mailing Address - Phone:207-453-9152
Mailing Address - Fax:
Practice Address - Street 1:131 OAKLAND RD
Practice Address - Street 2:
Practice Address - City:FAIRFIELD
Practice Address - State:ME
Practice Address - Zip Code:04937-3229
Practice Address - Country:US
Practice Address - Phone:207-453-9152
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-02-02
Last Update Date:2018-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320600000XResidential Treatment FacilitiesResidential Treatment Facility, Intellectual and/or Developmental Disabilities