Provider Demographics
NPI:1245653179
Name:DOUGLASS, SHAROLYN RENEE
Entity type:Individual
Prefix:
First Name:SHAROLYN
Middle Name:RENEE
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 1:5890 AUTUMN HARVEST AVE
Mailing Address - Street 2:AVE
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89142-0805
Mailing Address - Country:US
Mailing Address - Phone:702-219-5548
Mailing Address - Fax:
Practice Address - Street 1:5890 AUTUMN HARVEST AVE
Practice Address - Street 2:AVE
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89142-0805
Practice Address - Country:US
Practice Address - Phone:702-219-5548
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-01-29
Last Update Date:2014-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental Therapist