Provider Demographics
NPI:1760272702
Name:DOUGLAS, MARY DELORES
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:DELORES
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 1:513 N PINECREST RD
Mailing Address - Street 2:
Mailing Address - City:BOLINGBROOK
Mailing Address - State:IL
Mailing Address - Zip Code:60440-2139
Mailing Address - Country:US
Mailing Address - Phone:630-432-0156
Mailing Address - Fax:630-778-3998
Practice Address - Street 1:8201 CASS AVE
Practice Address - Street 2:
Practice Address - City:DARIEN
Practice Address - State:IL
Practice Address - Zip Code:60561-5314
Practice Address - Country:US
Practice Address - Phone:630-590-5571
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-05-12
Last Update Date:2025-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician