Provider Demographics
NPI:1457736134
Name:DEROBERTS, DOUGLAS C (LICDC II)
Entity type:Individual
Prefix:MR
First Name:DOUGLAS
Middle Name:C
Last Name:DEROBERTS
Suffix:
Gender:M
Credentials:LICDC II
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5209 DETROIT AVE
Mailing Address - Street 2:
Mailing Address - City:CLEVELAND
Mailing Address - State:OH
Mailing Address - Zip Code:44102-2224
Mailing Address - Country:US
Mailing Address - Phone:216-325-9123
Mailing Address - Fax:
Practice Address - Street 1:5209 DETROIT AVE
Practice Address - Street 2:
Practice Address - City:CLEVELAND
Practice Address - State:OH
Practice Address - Zip Code:44102-2224
Practice Address - Country:US
Practice Address - Phone:216-325-9123
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-07-23
Last Update Date:2024-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH060103101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)