Provider Demographics
NPI:1740494434
Name:DOUGLAS, ROSCOE LORMER (PHD)
Entity type:Individual
Prefix:
First Name:ROSCOE
Middle Name:LORMER
Last Name:DOUGLAS
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1207 WHITE OAK DR
Mailing Address - Street 2:
Mailing Address - City:MERIDIAN
Mailing Address - State:MS
Mailing Address - Zip Code:39305-1902
Mailing Address - Country:US
Mailing Address - Phone:601-493-9370
Mailing Address - Fax:601-482-4248
Practice Address - Street 1:1207 WHITE OAK DR
Practice Address - Street 2:
Practice Address - City:MERIDIAN
Practice Address - State:MS
Practice Address - Zip Code:39305-1902
Practice Address - Country:US
Practice Address - Phone:601-483-8370
Practice Address - Fax:601-482-4248
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS10 139103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00017960Medicaid