Provider Demographics
NPI:1164839262
Name:DOUGLAS, AUDREY (TLLP)
Entity Type:Individual
Prefix:
First Name:AUDREY
Middle Name:
Last Name:DOUGLAS
Suffix:
Gender:F
Credentials:TLLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:26559 BERG RD
Mailing Address - Street 2:APT 252
Mailing Address - City:SOUTHFIELD
Mailing Address - State:MI
Mailing Address - Zip Code:48033-2462
Mailing Address - Country:US
Mailing Address - Phone:313-522-3089
Mailing Address - Fax:
Practice Address - Street 1:9605 GRAND RIVER AVE
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48204-3129
Practice Address - Country:US
Practice Address - Phone:313-834-5930
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-07-21
Last Update Date:2014-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6301015838101YM0800X, 101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health