Provider Demographics
NPI:1962578765
Name:DOUGLAS, MICHELLE (MA, LPC)
Entity type:Individual
Prefix:
First Name:MICHELLE
Middle Name:
Last Name:DOUGLAS
Suffix:
Gender:F
Credentials:MA, LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:20475 STATE HWY 46 W
Mailing Address - Street 2:SUITE 180, PMB618
Mailing Address - City:SPRING BRANCH
Mailing Address - State:TX
Mailing Address - Zip Code:78070-6124
Mailing Address - Country:US
Mailing Address - Phone:830-515-8988
Mailing Address - Fax:830-438-8051
Practice Address - Street 1:222 CONEFLOWER DR
Practice Address - Street 2:
Practice Address - City:SPRING BRANCH
Practice Address - State:TX
Practice Address - Zip Code:78070-5039
Practice Address - Country:US
Practice Address - Phone:830-515-8988
Practice Address - Fax:830-438-8051
Is Sole Proprietor?:No
Enumeration Date:2006-11-27
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX19377101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX1795882Medicaid