Provider Demographics
NPI:1871017418
Name:DOUGLASS, REBECCA MARIE
Entity Type:Individual
Prefix:MRS
First Name:REBECCA
Middle Name:MARIE
Last Name:DOUGLASS
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 1:2110 S SANTA FE AVE APT 205
Mailing Address - Street 2:
Mailing Address - City:MOORE
Mailing Address - State:OK
Mailing Address - Zip Code:73160-2822
Mailing Address - Country:US
Mailing Address - Phone:402-452-0144
Mailing Address - Fax:
Practice Address - Street 1:301 W INTERSTATE 240 SERVICE RD
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73139
Practice Address - Country:US
Practice Address - Phone:405-605-4135
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-07-26
Last Update Date:2020-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator