Provider Demographics
NPI:1295855138
Name:BLACK, DOUGLAS LEE (LMP)
Entity Type:Individual
Prefix:
First Name:DOUGLAS
Middle Name:LEE
Last Name:BLACK
Suffix:
Gender:M
Credentials:LMP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6700 NE 162ND AVE STE 611
Mailing Address - Street 2:
Mailing Address - City:VANCOUVER
Mailing Address - State:WA
Mailing Address - Zip Code:98682-3899
Mailing Address - Country:US
Mailing Address - Phone:360-903-9963
Mailing Address - Fax:
Practice Address - Street 1:16906 SE 1ST ST STE 103
Practice Address - Street 2:
Practice Address - City:VANCOUVER
Practice Address - State:WA
Practice Address - Zip Code:98684-8512
Practice Address - Country:US
Practice Address - Phone:360-903-9963
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-31
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA00011374225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage TherapistGroup - Single Specialty