Provider Demographics
NPI:1679168793
Name:DOUGLAS, LETERRIOUS
Entity Type:Individual
Prefix:
First Name:LETERRIOUS
Middle Name:
Last Name:DOUGLAS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2897 BATTLE FORREST DR
Mailing Address - Street 2:
Mailing Address - City:DECATUR
Mailing Address - State:GA
Mailing Address - Zip Code:30034-2756
Mailing Address - Country:US
Mailing Address - Phone:404-348-6672
Mailing Address - Fax:
Practice Address - Street 1:2897 BATTLE FORREST DR
Practice Address - Street 2:
Practice Address - City:DECATUR
Practice Address - State:GA
Practice Address - Zip Code:30034-2756
Practice Address - Country:US
Practice Address - Phone:312-731-3944
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-03-02
Last Update Date:2021-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health