Provider Demographics
NPI:1912441924
Name:DOUGLAS, MIA STAR
Entity Type:Individual
Prefix:
First Name:MIA
Middle Name:STAR
Last Name:DOUGLAS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:560 CHARLES HAMILTON DR
Mailing Address - Street 2:
Mailing Address - City:COLLIERVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:38017-1667
Mailing Address - Country:US
Mailing Address - Phone:404-849-8080
Mailing Address - Fax:
Practice Address - Street 1:560 CHARLES HAMILTON DR
Practice Address - Street 2:
Practice Address - City:COLLIERVILLE
Practice Address - State:TN
Practice Address - Zip Code:38017-1667
Practice Address - Country:US
Practice Address - Phone:404-849-8080
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-12-09
Last Update Date:2016-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist