MEDICARE: DOUGLAS PSYCHOLOGICAL SERVICES LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	103TC0700X	Clinical Psychologist	6301013956	MI

General Provider Information

NPI Number	:	1174882914
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	DOUGLAS PSYCHOLOGICAL SERVICES LLC

Provider Business Mailing Address
First Line	:	624 W NEPESSING ST
Second Line	:	SUITE L2
City	:	LAPEER
State	:	MI
Zip	:	48446-2090
Country	:	US
Telephone Number	:	810-664-8060
Fax Number	:	810-245-8352

Provider Business Practice Location Address
First Line	:	624 W NEPESSING ST
Second Line	:	SUITE L2
City	:	LAPEER
State	:	MI
Zip	:	48446-2090
Country	:	US
Telephone Number	:	810-664-8060
Fax Number	:	810-245-8352

Authorized Official
Title or Position	:	CEO
Name	:	DR. DARRYL LEE DOUGLAS
Credential	:	PSYD
Telephone Number	:	810-664-8060

Provider Enumeration Date	:	05/14/2012
Last Update Date	:	05/14/2012

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