Provider Demographics
NPI:1528575370
Name:DOUGLASS, GWENDOLYN J
Entity Type:Individual
Prefix:
First Name:GWENDOLYN
Middle Name:J
Last Name:DOUGLASS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1506 AVENIDA DE LAS AMERICA
Mailing Address - Street 2:
Mailing Address - City:SANTA FE
Mailing Address - State:NM
Mailing Address - Zip Code:87507-5079
Mailing Address - Country:US
Mailing Address - Phone:413-588-4251
Mailing Address - Fax:
Practice Address - Street 1:1506 AVENIDA DE LAS AMERICA
Practice Address - Street 2:
Practice Address - City:SANTA FE
Practice Address - State:NM
Practice Address - Zip Code:87507-5079
Practice Address - Country:US
Practice Address - Phone:413-588-4251
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-01-02
Last Update Date:2018-01-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist