Provider Demographics
NPI:1891055307
Name:DOUGLAS, ROGER WILBUR (COTA)
Entity type:Individual
Prefix:
First Name:ROGER
Middle Name:WILBUR
Last Name:DOUGLAS
Suffix:
Gender:M
Credentials:COTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3353 MENDOCINO FOREST ST
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89122-3576
Mailing Address - Country:US
Mailing Address - Phone:702-606-8286
Mailing Address - Fax:
Practice Address - Street 1:3353 MENDOCINO FOREST ST
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89122-3576
Practice Address - Country:US
Practice Address - Phone:702-606-8286
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-05-18
Last Update Date:2012-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV08-1005224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant