Provider Demographics
NPI:1760097075
Name:DOUGLASS, KORY EICHERS MATHER
Entity Type:Individual
Prefix:
First Name:KORY
Middle Name:EICHERS MATHER
Last Name:DOUGLASS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:KORY
Other - Middle Name:EICHERS
Other - Last Name:DOUGLASS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:760 CENTER ST
Mailing Address - Street 2:
Mailing Address - City:PRAIRIE DU SAC
Mailing Address - State:WI
Mailing Address - Zip Code:53578-1212
Mailing Address - Country:US
Mailing Address - Phone:414-379-5756
Mailing Address - Fax:
Practice Address - Street 1:5979 SIGGELKOW RD
Practice Address - Street 2:
Practice Address - City:MCFARLAND
Practice Address - State:WI
Practice Address - Zip Code:53558-9817
Practice Address - Country:US
Practice Address - Phone:608-838-8999
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-09-14
Last Update Date:2020-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI754-228106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist