Provider Demographics
NPI:1316052822
Name:DOUGLAS, WILLIAM MICHAEL (MA, CCC-SLP, AVT)
Entity type:Individual
Prefix:
First Name:WILLIAM
Middle Name:MICHAEL
Last Name:DOUGLAS
Suffix:
Gender:M
Credentials:MA, CCC-SLP, AVT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:MEDICAL CENTER EAST SOUTH TOWER 1215 21ST AVE S
Mailing Address - Street 2:6422
Mailing Address - City:NASHVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37232-8718
Mailing Address - Country:US
Mailing Address - Phone:615-875-2412
Mailing Address - Fax:615-936-1225
Practice Address - Street 1:MEDICAL CENTER EAST SOUTH TOWER 1215 21ST AVE S
Practice Address - Street 2:6422
Practice Address - City:NASHVILLE
Practice Address - State:TN
Practice Address - Zip Code:37232-8718
Practice Address - Country:US
Practice Address - Phone:615-875-2412
Practice Address - Fax:615-936-1225
Is Sole Proprietor?:No
Enumeration Date:2006-08-21
Last Update Date:2013-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX17530235Z00000X
TN0000004920235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX87464TOtherBLUE SHIELD PROVIDER I D
TX005386002Medicaid