Provider Demographics
NPI:1992551691
Name:MADELINE C DOUGLAS
Entity type:Organization
Organization Name:MADELINE C DOUGLAS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MS
Authorized Official - First Name:MADELINE
Authorized Official - Middle Name:C
Authorized Official - Last Name:DOUGLAS
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:217-607-4215
Mailing Address - Street 1:PO BOX 1023
Mailing Address - Street 2:
Mailing Address - City:SAN BERNARDINO
Mailing Address - State:CA
Mailing Address - Zip Code:92402-1023
Mailing Address - Country:US
Mailing Address - Phone:217-607-4215
Mailing Address - Fax:909-495-1634
Practice Address - Street 1:1255 W COLTON AVE
Practice Address - Street 2:
Practice Address - City:REDLANDS
Practice Address - State:CA
Practice Address - Zip Code:92374-2861
Practice Address - Country:US
Practice Address - Phone:909-363-4661
Practice Address - Fax:909-495-1634
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-04-24
Last Update Date:2024-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)