Provider Demographics
NPI:1134956253
Name:DOUGLAS, GINA
Entity type:Individual
Prefix:
First Name:GINA
Middle Name:
Last Name:DOUGLAS
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 1:20167 TUCKER RD
Mailing Address - Street 2:
Mailing Address - City:OAKBORO
Mailing Address - State:NC
Mailing Address - Zip Code:28129-9468
Mailing Address - Country:US
Mailing Address - Phone:828-712-4269
Mailing Address - Fax:
Practice Address - Street 1:1546 HIGHWAY 27 W STE 107
Practice Address - Street 2:
Practice Address - City:ALBEMARLE
Practice Address - State:NC
Practice Address - Zip Code:28001-6413
Practice Address - Country:US
Practice Address - Phone:704-248-7329
Practice Address - Fax:704-248-8340
Is Sole Proprietor?:Yes
Enumeration Date:2024-09-14
Last Update Date:2024-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCA20472101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health