Provider Demographics
NPI:1124169404
Name:DOUGLAS EDUCATION SERVICE DISTRICT
Entity type:Organization
Organization Name:DOUGLAS EDUCATION SERVICE DISTRICT
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:EI/ECSE REGIONAL DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:SUSAN
Authorized Official - Middle Name:C
Authorized Official - Last Name:GRAHAM
Authorized Official - Suffix:
Authorized Official - Credentials:MS, CCC
Authorized Official - Phone:541-440-4792
Mailing Address - Street 1:1871 NE STEPHENS STREET
Mailing Address - Street 2:
Mailing Address - City:ROSEBURG
Mailing Address - State:OR
Mailing Address - Zip Code:97470
Mailing Address - Country:US
Mailing Address - Phone:541-440-4777
Mailing Address - Fax:541-440-4771
Practice Address - Street 1:1871 NE STEPHENS STRET
Practice Address - Street 2:
Practice Address - City:ROSEBURG
Practice Address - State:OR
Practice Address - Zip Code:97470
Practice Address - Country:US
Practice Address - Phone:541-440-4777
Practice Address - Fax:541-440-4771
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-09
Last Update Date:2012-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR251300000X
251300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251300000XAgenciesLocal Education Agency (LEA)
Provider Identifiers
StateIdentifier IDID TypeIssuer
ORDMAP018700Medicaid
OR018700Medicaid