Provider Demographics
NPI:1881077485
Name:DOUGLAS, BERNARD (MA)
Entity type:Individual
Prefix:
First Name:BERNARD
Middle Name:
Last Name:DOUGLAS
Suffix:
Gender:M
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6535 WILSHIRE BLVD
Mailing Address - Street 2:SUITE 103
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90048-4905
Mailing Address - Country:US
Mailing Address - Phone:213-373-1938
Mailing Address - Fax:213-226-0556
Practice Address - Street 1:6535 WILSHIRE BLVD
Practice Address - Street 2:SUITE 103
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90048-4905
Practice Address - Country:US
Practice Address - Phone:213-373-1938
Practice Address - Fax:213-226-0556
Is Sole Proprietor?:No
Enumeration Date:2015-07-01
Last Update Date:2015-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAIMF78566106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist