Provider Demographics
NPI:1265610273
Name:DOUGLAS, PAULETTE (MFT)
Entity type:Individual
Prefix:
First Name:PAULETTE
Middle Name:
Last Name:DOUGLAS
Suffix:
Gender:F
Credentials:MFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11776 NAVEL AVE
Mailing Address - Street 2:
Mailing Address - City:MORENO VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:92557-6643
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:23800 SUNNYMEAD BLVD STE D
Practice Address - Street 2:
Practice Address - City:MORENO VALLEY
Practice Address - State:CA
Practice Address - Zip Code:92553-7731
Practice Address - Country:US
Practice Address - Phone:310-420-5341
Practice Address - Fax:800-313-0140
Is Sole Proprietor?:No
Enumeration Date:2008-02-01
Last Update Date:2019-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA49399106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist