Provider Demographics
NPI:1598825747
Name:DOUGLASS, DEIRDRE DOLAN (PT)
Entity Type:Individual
Prefix:
First Name:DEIRDRE
Middle Name:DOLAN
Last Name:DOUGLASS
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:586 CLUBLAND CIR SE
Mailing Address - Street 2:
Mailing Address - City:CONYERS
Mailing Address - State:GA
Mailing Address - Zip Code:30094-3626
Mailing Address - Country:US
Mailing Address - Phone:770-785-7908
Mailing Address - Fax:770-785-7908
Practice Address - Street 1:586 CLUBLAND CIR SE
Practice Address - Street 2:
Practice Address - City:CONYERS
Practice Address - State:GA
Practice Address - Zip Code:30094-3626
Practice Address - Country:US
Practice Address - Phone:770-785-7908
Practice Address - Fax:770-785-7908
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-11
Last Update Date:2012-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPT0032722251P0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251P0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA322094Medicaid
GA000711763BMedicaid
GA10057878Medicaid