Provider Demographics
NPI:1821396722
Name:WEST, DOUGLAS A (ATC)
Entity Type:Individual
Prefix:MR
First Name:DOUGLAS
Middle Name:A
Last Name:WEST
Suffix:
Gender:M
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1205 N LIVINGSTON ST
Mailing Address - Street 2:
Mailing Address - City:BLOOMINGTON
Mailing Address - State:IL
Mailing Address - Zip Code:61701-1534
Mailing Address - Country:US
Mailing Address - Phone:309-838-3640
Mailing Address - Fax:
Practice Address - Street 1:1701 E COLLEGE AVE
Practice Address - Street 2:
Practice Address - City:BLOOMINGTON
Practice Address - State:IL
Practice Address - Zip Code:61704-2101
Practice Address - Country:US
Practice Address - Phone:309-664-3038
Practice Address - Fax:309-664-3119
Is Sole Proprietor?:No
Enumeration Date:2011-03-02
Last Update Date:2011-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0960030322255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer