Provider Demographics
NPI:1306042551
Name:DOUGLAS, KORY L (PLMP)
Entity Type:Individual
Prefix:
First Name:KORY
Middle Name:L
Last Name:DOUGLAS
Suffix:
Gender:F
Credentials:PLMP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15 E CENTRAL AVE STE 3
Mailing Address - Street 2:
Mailing Address - City:SPOKANE
Mailing Address - State:WA
Mailing Address - Zip Code:99208-1109
Mailing Address - Country:US
Mailing Address - Phone:509-487-5717
Mailing Address - Fax:509-487-0207
Practice Address - Street 1:15 E CENTRAL AVE STE 3
Practice Address - Street 2:
Practice Address - City:SPOKANE
Practice Address - State:WA
Practice Address - Zip Code:99208-1109
Practice Address - Country:US
Practice Address - Phone:509-487-5717
Practice Address - Fax:509-487-0207
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA18874225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist