MEDICARE: THERESSE ELIZABETH GIBBS DOUGLASS

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	363LP0808X	Psychiatric/Mental Health Nurse Practitioner	AP30000194	WA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1356378921
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	THERESSE ELIZABETH GIBBS DOUGLASS

Provider Business Mailing Address
First Line	:	6863 EAGLE HARBOR DR NE
Second Line	:
City	:	BAINBRIDGE ISLAND
State	:	WA
Zip	:	98110-3103
Country	:	US
Telephone Number	:	206-780-3401
Fax Number	:	206-238-9777

Provider Business Practice Location Address
First Line	:	6863 EAGLE HARBOR DR NE
Second Line	:
City	:	BAINBRIDGE ISLAND
State	:	WA
Zip	:	98110-3103
Country	:	US
Telephone Number	:	206-780-3401
Fax Number	:	206-238-9777

Authorized Official
Title or Position	:	SOLE PROPRIETOR
Name	:	DR. THERESSE (TERRY) ELIZABETH DOUGLASS
Credential	:	ARNP, PHD
Telephone Number	:	206-780-3401

Provider Enumeration Date	:	06/27/2006
Last Update Date	:	11/14/2014

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