Provider Demographics
NPI:1598341083
Name:DOUGLASS, RICHARD (PHD)
Entity Type:Individual
Prefix:
First Name:RICHARD
Middle Name:
Last Name:DOUGLASS
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 1:5200 WILLSON RD STE 150
Mailing Address - Street 2:
Mailing Address - City:EDINA
Mailing Address - State:MN
Mailing Address - Zip Code:55424-1300
Mailing Address - Country:US
Mailing Address - Phone:612-433-3065
Mailing Address - Fax:
Practice Address - Street 1:5200 WILLSON RD STE 150
Practice Address - Street 2:
Practice Address - City:EDINA
Practice Address - State:MN
Practice Address - Zip Code:55424-1300
Practice Address - Country:US
Practice Address - Phone:612-433-3065
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-03-23
Last Update Date:2021-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNLP6656103TC1900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounseling