Provider Demographics
NPI:1184931610
Name:DOUGLAS, SEGORNAE BEULAH-ZOE (OTR/L)
Entity type:Individual
Prefix:
First Name:SEGORNAE
Middle Name:BEULAH-ZOE
Last Name:DOUGLAS
Suffix:
Gender:F
Credentials:OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12509 E MISSION AVE STE 202
Mailing Address - Street 2:
Mailing Address - City:SPOKANE VALLEY
Mailing Address - State:WA
Mailing Address - Zip Code:99216-1062
Mailing Address - Country:US
Mailing Address - Phone:509-444-5678
Mailing Address - Fax:509-343-5678
Practice Address - Street 1:12509 E MISSION AVE STE 202
Practice Address - Street 2:
Practice Address - City:SPOKANE VALLEY
Practice Address - State:WA
Practice Address - Zip Code:99216-1062
Practice Address - Country:US
Practice Address - Phone:509-444-5678
Practice Address - Fax:509-343-5678
Is Sole Proprietor?:No
Enumeration Date:2010-09-03
Last Update Date:2010-09-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAOT60139321225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist