Provider Demographics
NPI:1588904122
Name:DOUGLAS, RICHARD P (BCBA)
Entity type:Individual
Prefix:
First Name:RICHARD
Middle Name:P
Last Name:DOUGLAS
Suffix:
Gender:
Credentials:BCBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2228 BLACK ROCK TPKE STE 302
Mailing Address - Street 2:
Mailing Address - City:FAIRFIELD
Mailing Address - State:CT
Mailing Address - Zip Code:06825-3237
Mailing Address - Country:US
Mailing Address - Phone:203-292-6949
Mailing Address - Fax:
Practice Address - Street 1:2228 BLACK ROCK TPKE STE 302
Practice Address - Street 2:
Practice Address - City:FAIRFIELD
Practice Address - State:CT
Practice Address - Zip Code:06825-3237
Practice Address - Country:US
Practice Address - Phone:203-292-6949
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-02-19
Last Update Date:2025-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT1-19-36988103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT0-14-5069OtherBACB