Provider Demographics
NPI:1770011207
Name:DOUGLAS, ASHLEY NICOLE
Entity Type:Individual
Prefix:
First Name:ASHLEY
Middle Name:NICOLE
Last Name:DOUGLAS
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 1:21885 DUNHAM RD
Mailing Address - Street 2:
Mailing Address - City:CLINTON TOWNSHIP
Mailing Address - State:MI
Mailing Address - Zip Code:48036-1030
Mailing Address - Country:US
Mailing Address - Phone:586-469-5950
Mailing Address - Fax:
Practice Address - Street 1:21885 DUNHAM RD
Practice Address - Street 2:
Practice Address - City:CLINTON TOWNSHIP
Practice Address - State:MI
Practice Address - Zip Code:48036-1030
Practice Address - Country:US
Practice Address - Phone:586-469-5950
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-05-29
Last Update Date:2021-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI68511009671041C0700X
MI6801100967104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical