Provider Demographics
NPI:1356378921
Name:THERESSE ELIZABETH GIBBS DOUGLASS
Entity type:Organization
Organization Name:THERESSE ELIZABETH GIBBS DOUGLASS
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:SOLE PROPRIETOR
Authorized Official - Prefix:DR
Authorized Official - First Name:THERESSE (TERRY)
Authorized Official - Middle Name:ELIZABETH
Authorized Official - Last Name:DOUGLASS
Authorized Official - Suffix:
Authorized Official - Credentials:ARNP, PHD
Authorized Official - Phone:206-780-3401
Mailing Address - Street 1:6863 EAGLE HARBOR DR NE
Mailing Address - Street 2:
Mailing Address - City:BAINBRIDGE ISLAND
Mailing Address - State:WA
Mailing Address - Zip Code:98110-3103
Mailing Address - Country:US
Mailing Address - Phone:206-780-3401
Mailing Address - Fax:206-238-9777
Practice Address - Street 1:6863 EAGLE HARBOR DR NE
Practice Address - Street 2:
Practice Address - City:BAINBRIDGE ISLAND
Practice Address - State:WA
Practice Address - Zip Code:98110-3103
Practice Address - Country:US
Practice Address - Phone:206-780-3401
Practice Address - Fax:206-238-9777
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-27
Last Update Date:2014-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAAP30000194363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA9605122Medicaid
GAB09751Medicare PIN
WA9605122Medicaid