Provider Demographics
NPI:1124667357
Name:DOUGLAS, AYANA
Entity type:Individual
Prefix:
First Name:AYANA
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 1:2545 WARREGO WAY
Mailing Address - Street 2:
Mailing Address - City:SACRAMENTO
Mailing Address - State:CA
Mailing Address - Zip Code:95826-2433
Mailing Address - Country:US
Mailing Address - Phone:916-291-9121
Mailing Address - Fax:
Practice Address - Street 1:2545 WARREGO WAY
Practice Address - Street 2:
Practice Address - City:SACRAMENTO
Practice Address - State:CA
Practice Address - Zip Code:95826-2433
Practice Address - Country:US
Practice Address - Phone:916-291-9121
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-01-06
Last Update Date:2020-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAE2546162103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst