Provider Demographics
NPI:1235554031
Name:DOUGLAS, NATALIE BK (BA, MS, DT, RBT)
Entity Type:Individual
Prefix:
First Name:NATALIE
Middle Name:BK
Last Name:DOUGLAS
Suffix:
Gender:F
Credentials:BA, MS, DT, RBT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9534 E TESLA AVE
Mailing Address - Street 2:
Mailing Address - City:MESA
Mailing Address - State:AZ
Mailing Address - Zip Code:85212-6412
Mailing Address - Country:US
Mailing Address - Phone:847-877-5336
Mailing Address - Fax:
Practice Address - Street 1:1627 W FARGO AVE
Practice Address - Street 2:UNIT 3S
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60626-1750
Practice Address - Country:US
Practice Address - Phone:847-877-5336
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-03-03
Last Update Date:2022-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZBACB699230374700000X
390200000X, 106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
No374700000XNursing Service Related ProvidersTechnician
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program