Provider Demographics
NPI:1821269150
Name:DOUGLAS, DARRYL L (PSYD)
Entity Type:Individual
Prefix:DR
First Name:DARRYL
Middle Name:L
Last Name:DOUGLAS
Suffix:
Gender:M
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:624 W NEPESSING ST STE L2
Mailing Address - Street 2:P.O. BOX 985
Mailing Address - City:LAPEER
Mailing Address - State:MI
Mailing Address - Zip Code:48446-2086
Mailing Address - Country:US
Mailing Address - Phone:810-664-8060
Mailing Address - Fax:810-245-8352
Practice Address - Street 1:624 W NEPESSING ST STE L2
Practice Address - Street 2:
Practice Address - City:LAPEER
Practice Address - State:MI
Practice Address - Zip Code:48446-2086
Practice Address - Country:US
Practice Address - Phone:810-664-8060
Practice Address - Fax:810-245-8352
Is Sole Proprietor?:Yes
Enumeration Date:2008-03-14
Last Update Date:2010-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6301012309103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist