Provider Demographics
NPI:1558840637
Name:DOUGLASS, NATHAN
Entity Type:Individual
Prefix:
First Name:NATHAN
Middle Name:
Last Name:DOUGLASS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12503 SE MILL PLAIN BLVD STE 119A
Mailing Address - Street 2:
Mailing Address - City:VANCOUVER
Mailing Address - State:WA
Mailing Address - Zip Code:98684-4007
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:12503 SE MILL PLAIN BLVD STE 119A
Practice Address - Street 2:
Practice Address - City:VANCOUVER
Practice Address - State:WA
Practice Address - Zip Code:98684-4007
Practice Address - Country:US
Practice Address - Phone:360-314-6507
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-08-09
Last Update Date:2018-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WACO60808571101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)