Provider Demographics
NPI:1114232725
Name:DOUGLAS, BRENT ALLEN (MA, LMHC)
Entity Type:Individual
Prefix:
First Name:BRENT
Middle Name:ALLEN
Last Name:DOUGLAS
Suffix:
Gender:M
Credentials:MA, LMHC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3237 E WASHINGTON AVE
Mailing Address - Street 2:
Mailing Address - City:DES MOINES
Mailing Address - State:IA
Mailing Address - Zip Code:50317-8654
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:6390 NE RISING SUN DR
Practice Address - Street 2:
Practice Address - City:PLEASANT HILL
Practice Address - State:IA
Practice Address - Zip Code:50327-2178
Practice Address - Country:US
Practice Address - Phone:515-953-9083
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-08-09
Last Update Date:2013-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA001256101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health