Provider Demographics
NPI:1174844476
Name:DOUGLAS, NICHOLE KRISTEN
Entity Type:Individual
Prefix:
First Name:NICHOLE
Middle Name:KRISTEN
Last Name:DOUGLAS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1289 SEGHESIO WAY
Mailing Address - Street 2:
Mailing Address - City:WINDSOR
Mailing Address - State:CA
Mailing Address - Zip Code:95492-7711
Mailing Address - Country:US
Mailing Address - Phone:707-695-2916
Mailing Address - Fax:707-565-8689
Practice Address - Street 1:1289 SEGHESIO WAY
Practice Address - Street 2:
Practice Address - City:WINDSOR
Practice Address - State:CA
Practice Address - Zip Code:95492-7711
Practice Address - Country:US
Practice Address - Phone:707-695-2916
Practice Address - Fax:707-565-8689
Is Sole Proprietor?:No
Enumeration Date:2010-06-21
Last Update Date:2012-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor