Provider Demographics
NPI:1891842274
Name:DOUGLAS, MARY (OTRL, CHT)
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:
Last Name:DOUGLAS
Suffix:
Gender:F
Credentials:OTRL, CHT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1112 CAROLINE ST
Mailing Address - Street 2:
Mailing Address - City:PORT ANGELES
Mailing Address - State:WA
Mailing Address - Zip Code:98362-4204
Mailing Address - Country:US
Mailing Address - Phone:360-417-8630
Mailing Address - Fax:360-417-8635
Practice Address - Street 1:1112 CAROLINE ST
Practice Address - Street 2:
Practice Address - City:PORT ANGELES
Practice Address - State:WA
Practice Address - Zip Code:98362-4204
Practice Address - Country:US
Practice Address - Phone:360-417-8630
Practice Address - Fax:360-417-8635
Is Sole Proprietor?:No
Enumeration Date:2007-01-05
Last Update Date:2013-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAOT00003831225X00000X, 225XH1200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
No225XH1200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistHand
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA0304760OtherL&I
WA8399149Medicaid
WA0304760OtherL&I
WAG8915427Medicare PIN