Provider Demographics
NPI:1902248982
Name:DOUGLAS, MARTHA JANE (MA, CCC-SLP)
Entity type:Individual
Prefix:
First Name:MARTHA
Middle Name:JANE
Last Name:DOUGLAS
Suffix:
Gender:F
Credentials:MA, CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:190094 UNIVERSITY ST
Mailing Address - Street 2:
Mailing Address - City:SCOTTSBLUFF
Mailing Address - State:NE
Mailing Address - Zip Code:69361-5752
Mailing Address - Country:US
Mailing Address - Phone:308-635-6689
Mailing Address - Fax:
Practice Address - Street 1:2101 BOX BUTTE AVE
Practice Address - Street 2:
Practice Address - City:ALLIANCE
Practice Address - State:NE
Practice Address - Zip Code:69301-4445
Practice Address - Country:US
Practice Address - Phone:308-761-3372
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-07-19
Last Update Date:2013-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE371235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist