Provider Demographics
NPI:1346807112
Name:DOUGLAS, SHARESE JOELL (LPTA)
Entity Type:Individual
Prefix:
First Name:SHARESE
Middle Name:JOELL
Last Name:DOUGLAS
Suffix:
Gender:F
Credentials:LPTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:728 CORAPEAKE DR
Mailing Address - Street 2:
Mailing Address - City:CHESAPEAKE
Mailing Address - State:VA
Mailing Address - Zip Code:23322-7914
Mailing Address - Country:US
Mailing Address - Phone:577-353-7653
Mailing Address - Fax:
Practice Address - Street 1:1015 W 47TH ST
Practice Address - Street 2:
Practice Address - City:NORFOLK
Practice Address - State:VA
Practice Address - Zip Code:23508
Practice Address - Country:US
Practice Address - Phone:757-683-7041
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-05-28
Last Update Date:2019-05-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant