Provider Demographics
NPI:1578233995
Name:DOUGLAS, AMBER (RBT)
Entity Type:Individual
Prefix:
First Name:AMBER
Middle Name:
Last Name:DOUGLAS
Suffix:
Gender:F
Credentials:RBT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10175 FORTUNE PKWY UNIT 903
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32256-6755
Mailing Address - Country:US
Mailing Address - Phone:904-538-0713
Mailing Address - Fax:904-538-0714
Practice Address - Street 1:101 SAINT GEORGE BLVD APT 75
Practice Address - Street 2:
Practice Address - City:SAVANNAH
Practice Address - State:GA
Practice Address - Zip Code:31419-9344
Practice Address - Country:US
Practice Address - Phone:724-601-3466
Practice Address - Fax:904-538-0714
Is Sole Proprietor?:No
Enumeration Date:2021-09-16
Last Update Date:2022-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA21-182463106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician