Provider Demographics
NPI:1134512262
Name:DOUGLAS, TRICIA (ATS)
Entity Type:Individual
Prefix:
First Name:TRICIA
Middle Name:
Last Name:DOUGLAS
Suffix:
Gender:F
Credentials:ATS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:881 W WALNUT ST
Mailing Address - Street 2:
Mailing Address - City:SAINT CHARLES
Mailing Address - State:MI
Mailing Address - Zip Code:48655-1257
Mailing Address - Country:US
Mailing Address - Phone:989-865-2400
Mailing Address - Fax:
Practice Address - Street 1:881 W WALNUT ST
Practice Address - Street 2:
Practice Address - City:SAINT CHARLES
Practice Address - State:MI
Practice Address - Zip Code:48655-1257
Practice Address - Country:US
Practice Address - Phone:989-865-2400
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-03-13
Last Update Date:2015-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI2255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer