Provider Demographics
NPI:1639332711
Name:DOUGLASS, CHARISSE ELIZABETH
Entity Type:Individual
Prefix:
First Name:CHARISSE
Middle Name:ELIZABETH
Last Name:DOUGLASS
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 1:2811 LA QUINTA DR
Mailing Address - Street 2:1104D
Mailing Address - City:SACRAMENTO
Mailing Address - State:CA
Mailing Address - Zip Code:95826-3477
Mailing Address - Country:US
Mailing Address - Phone:916-567-4222
Mailing Address - Fax:916-567-4220
Practice Address - Street 1:601W NORTH MARKET BLVD.
Practice Address - Street 2:STE. 100
Practice Address - City:SACRAMENTO
Practice Address - State:CA
Practice Address - Zip Code:95826
Practice Address - Country:US
Practice Address - Phone:916-567-4222
Practice Address - Fax:916-567-4220
Is Sole Proprietor?:No
Enumeration Date:2008-07-08
Last Update Date:2008-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health