Provider Demographics
NPI:1952902686
Name:DOUGLAS, DEANDREA MICHELLE (JST)
Entity type:Individual
Prefix:
First Name:DEANDREA
Middle Name:MICHELLE
Last Name:DOUGLAS
Suffix:
Gender:F
Credentials:JST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1445 LAKESIDE ESTATES DR APT 2102
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77042-2490
Mailing Address - Country:US
Mailing Address - Phone:281-248-6109
Mailing Address - Fax:281-715-5515
Practice Address - Street 1:239 W TIDWELL RD STE F1
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77022-1528
Practice Address - Country:US
Practice Address - Phone:281-248-6109
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-11-09
Last Update Date:2020-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXDDOUGL73251C00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251C00000XAgenciesDay Training, Developmentally Disabled Services
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXDDOUGL73OtherUNT WISE VOCATIONAL SERVICES