Provider Demographics
NPI:1477691418
Name:CHEATHAM, DOUGLAS RAY (PHD)
Entity Type:Individual
Prefix:
First Name:DOUGLAS
Middle Name:RAY
Last Name:CHEATHAM
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 190408
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75219-0408
Mailing Address - Country:US
Mailing Address - Phone:214-207-5664
Mailing Address - Fax:888-765-7459
Practice Address - Street 1:100 N COLLEGE
Practice Address - Street 2:SUITE 302
Practice Address - City:WAXAHACHIE
Practice Address - State:TX
Practice Address - Zip Code:75165-3702
Practice Address - Country:US
Practice Address - Phone:214-207-5664
Practice Address - Fax:888-765-7459
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-02
Last Update Date:2010-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX22513103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX751993921OtherINTEGRATED MENTAL HEALTH SERVICES
TX098373602Medicaid
TX81960POtherBCBSTX
TX126296OtherTEXAS NORTHSTAR, VALUE OP
TX7365201OtherBLUELIKK
TX751993021OtherMAGELLAN