Provider Demographics
NPI:1063872794
Name:DOUGLAS, CHRISTA
Entity type:Individual
Prefix:
First Name:CHRISTA
Middle Name:
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 1:8840 CYPRESS WATERS BLVD
Mailing Address - Street 2:SUITE 300
Mailing Address - City:COPPELL
Mailing Address - State:TX
Mailing Address - Zip Code:75019-4594
Mailing Address - Country:US
Mailing Address - Phone:866-858-7580
Mailing Address - Fax:
Practice Address - Street 1:308 PINE VALLEY DR
Practice Address - Street 2:
Practice Address - City:YADKINVILLE
Practice Address - State:NC
Practice Address - Zip Code:27055-6875
Practice Address - Country:US
Practice Address - Phone:866-858-7580
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-02-23
Last Update Date:2016-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDA02235224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant