Provider Demographics
NPI:1437492311
Name:DOUGLAS, ROSSLYN (PSYD)
Entity Type:Individual
Prefix:
First Name:ROSSLYN
Middle Name:
Last Name:DOUGLAS
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1503 PALO DURO CANYON DR
Mailing Address - Street 2:
Mailing Address - City:LEAGUE CITY
Mailing Address - State:TX
Mailing Address - Zip Code:77573-6498
Mailing Address - Country:US
Mailing Address - Phone:832-425-8363
Mailing Address - Fax:
Practice Address - Street 1:2600 S SHORE BLVD STE 300
Practice Address - Street 2:
Practice Address - City:LEAGUE CITY
Practice Address - State:TX
Practice Address - Zip Code:77573-2944
Practice Address - Country:US
Practice Address - Phone:832-425-8363
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-03-29
Last Update Date:2019-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX36396103T00000X, 103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103T00000XBehavioral Health & Social Service ProvidersPsychologist