Provider Demographics
NPI:1417209164
Name:DOUGLASS, PURAN (PSYD)
Entity Type:Individual
Prefix:DR
First Name:PURAN
Middle Name:
Last Name:DOUGLASS
Suffix:
Gender:M
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8233 OLD COURTHOUSE RD STE 102
Mailing Address - Street 2:
Mailing Address - City:VIENNA
Mailing Address - State:VA
Mailing Address - Zip Code:22182-3816
Mailing Address - Country:US
Mailing Address - Phone:703-924-2370
Mailing Address - Fax:703-924-2374
Practice Address - Street 1:8233 OLD COURTHOUSE RD STE 102
Practice Address - Street 2:
Practice Address - City:VIENNA
Practice Address - State:VA
Practice Address - Zip Code:22182-3816
Practice Address - Country:US
Practice Address - Phone:703-924-2370
Practice Address - Fax:703-924-2374
Is Sole Proprietor?:Yes
Enumeration Date:2012-10-04
Last Update Date:2024-01-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
103TA0400X
VA0810004653103TB0200X, 103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103TA0400XBehavioral Health & Social Service ProvidersPsychologistAddiction (Substance Use Disorder)
No103TB0200XBehavioral Health & Social Service ProvidersPsychologistCognitive & Behavioral