Provider Demographics
NPI:1770377764
Name:DOUGLAS, TIA DEBRAH
Entity type:Individual
Prefix:MS
First Name:TIA
Middle Name:DEBRAH
Last Name:DOUGLAS
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1324 S CASINO CENTER BLVD UNIT 8
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89104-1134
Mailing Address - Country:US
Mailing Address - Phone:702-581-8160
Mailing Address - Fax:
Practice Address - Street 1:1324 S CASINO CENTER BLVD UNIT 8
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89104-1134
Practice Address - Country:US
Practice Address - Phone:702-581-8160
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-04-07
Last Update Date:2025-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV3183225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist