Provider Demographics
NPI:1568708139
Name:DOUGLAS, CORTNEY D
Entity Type:Individual
Prefix:
First Name:CORTNEY
Middle Name:D
Last Name:DOUGLAS
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 1:8203 NW 31ST AVE APT E29
Mailing Address - Street 2:
Mailing Address - City:GAINESVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32606-6220
Mailing Address - Country:US
Mailing Address - Phone:352-870-1268
Mailing Address - Fax:
Practice Address - Street 1:8203 NW 31ST AVE APT E29
Practice Address - Street 2:
Practice Address - City:GAINESVILLE
Practice Address - State:FL
Practice Address - Zip Code:32606
Practice Address - Country:US
Practice Address - Phone:352-870-1268
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-12-29
Last Update Date:2018-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
172V00000X
FL008397800372600000X, 385HR2055X, 385HR2065X, 385HR2060X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes385HR2060XRespite Care FacilityRespite CareRespite Care, Intellectual and/or Developmental Disabilities, Child
No172V00000XOther Service ProvidersCommunity Health Worker
No372600000XNursing Service Related ProvidersAdult Companion
No385HR2055XRespite Care FacilityRespite CareRespite Care, Mental Illness, Child
No385HR2065XRespite Care FacilityRespite CareRespite Care, Physical Disabilities, Child
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL008397800Medicaid