Provider Demographics
NPI:1396720496
Name:DOUGLAS, JANIS MARIE
Entity type:Individual
Prefix:
First Name:JANIS
Middle Name:MARIE
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 1:70 MUSSEL BED SHOAL RD
Mailing Address - Street 2:
Mailing Address - City:PORTSMOUTH
Mailing Address - State:RI
Mailing Address - Zip Code:02871-2012
Mailing Address - Country:US
Mailing Address - Phone:401-662-7351
Mailing Address - Fax:
Practice Address - Street 1:42 VALLEY RD
Practice Address - Street 2:
Practice Address - City:MIDDLETOWN
Practice Address - State:RI
Practice Address - Zip Code:02842-6400
Practice Address - Country:US
Practice Address - Phone:401-431-9870
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-12-12
Last Update Date:2020-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RIMHC 00265101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
RI412885OtherBLUE CHIP
RI29911-2OtherBLUE CROSS
RIJK52562Medicaid