Provider Demographics
NPI:1154956829
Name:DOUGLAS, NICOLE LEE (ASSOCIATE MFT)
Entity type:Individual
Prefix:
First Name:NICOLE
Middle Name:LEE
Last Name:DOUGLAS
Suffix:
Gender:F
Credentials:ASSOCIATE MFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1757 AVILA RANCH DR
Mailing Address - Street 2:
Mailing Address - City:PETALUMA
Mailing Address - State:CA
Mailing Address - Zip Code:94954-8522
Mailing Address - Country:US
Mailing Address - Phone:415-823-8647
Mailing Address - Fax:
Practice Address - Street 1:3434 MENDOCINO AVE # A
Practice Address - Street 2:
Practice Address - City:SANTA ROSA
Practice Address - State:CA
Practice Address - Zip Code:95403-2274
Practice Address - Country:US
Practice Address - Phone:707-284-1978
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-03-03
Last Update Date:2020-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA112167101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health