Provider Demographics
NPI:1972862688
Name:DOUGLASS, CHRISTINE MAY
Entity Type:Individual
Prefix:MRS
First Name:CHRISTINE
Middle Name:MAY
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 1:314 E AVENUE K4
Mailing Address - Street 2:SUITE 104
Mailing Address - City:LANCASTER
Mailing Address - State:CA
Mailing Address - Zip Code:93535-4689
Mailing Address - Country:US
Mailing Address - Phone:661-726-5500
Mailing Address - Fax:
Practice Address - Street 1:314 E AVENUE K4
Practice Address - Street 2:SUITE 104
Practice Address - City:LANCASTER
Practice Address - State:CA
Practice Address - Zip Code:93535-4689
Practice Address - Country:US
Practice Address - Phone:661-726-5500
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-05-15
Last Update Date:2017-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA69088106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA95-2633765OtherMEDI-CAL