Provider Demographics
NPI:1871646752
Name:BAIN, DOUGLAS ALBERT
Entity Type:Individual
Prefix:MR
First Name:DOUGLAS
Middle Name:ALBERT
Last Name:BAIN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 2619
Mailing Address - Street 2:
Mailing Address - City:MAMMOTH LAKES
Mailing Address - State:CA
Mailing Address - Zip Code:93546-2619
Mailing Address - Country:US
Mailing Address - Phone:760-924-1740
Mailing Address - Fax:760-924-1741
Practice Address - Street 1:452 OLD MAMMOTH ROAD
Practice Address - Street 2:SUITE K
Practice Address - City:MAMMOTH LAKES
Practice Address - State:CA
Practice Address - Zip Code:93546-2619
Practice Address - Country:US
Practice Address - Phone:760-924-1740
Practice Address - Fax:760-924-1741
Is Sole Proprietor?:No
Enumeration Date:2007-01-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health