Provider Demographics
NPI:1093939944
Name:COL, DOUGLAS A (PHD)
Entity Type:Individual
Prefix:
First Name:DOUGLAS
Middle Name:A
Last Name:COL
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:542 WASHINGTON ST
Mailing Address - Street 2:STE 200
Mailing Address - City:ASHLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97520
Mailing Address - Country:US
Mailing Address - Phone:541-488-6941
Mailing Address - Fax:541-488-6951
Practice Address - Street 1:542 WASHINGTON ST
Practice Address - Street 2:STE 200
Practice Address - City:ASHLAND
Practice Address - State:OR
Practice Address - Zip Code:97520
Practice Address - Country:US
Practice Address - Phone:541-488-6941
Practice Address - Fax:541-488-6951
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-12
Last Update Date:2016-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR1346103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR295715Medicaid
ORR106323OtherMEDICARE ID-PIN
OR295715Medicaid
ORR106323Medicare PIN