Provider Demographics
NPI:1902642911
Name:DOUGE, KEIVENCIA PELIA ANNE MYRTEL
Entity type:Individual
Prefix:
First Name:KEIVENCIA
Middle Name:PELIA ANNE MYRTEL
Last Name:DOUGE
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 1:711 21ST AVE APT 3
Mailing Address - Street 2:
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98122-4737
Mailing Address - Country:US
Mailing Address - Phone:832-949-9626
Mailing Address - Fax:
Practice Address - Street 1:12826 SE 40TH LN STE A10
Practice Address - Street 2:
Practice Address - City:BELLEVUE
Practice Address - State:WA
Practice Address - Zip Code:98006-5266
Practice Address - Country:US
Practice Address - Phone:832-949-9626
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-07-08
Last Update Date:2024-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA61458410106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician