Healthcare Provider Details

I. General information

NPI: 1407579949
Provider Name (Legal Business Name): DOUGLAS OWUSU
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/20/2022
Last Update Date: 09/20/2022
Certification Date: 08/23/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2406 S 24TH ST STE 103
PHOENIX AZ
85034-6822
US

IV. Provider business mailing address

3101 N CENTRAL AVE STE 1832266
PHOENIX AZ
85012-2645
US

V. Phone/Fax

Practice location:
  • Phone: 630-532-3036
  • Fax: 310-388-5269
Mailing address:
  • Phone: 630-532-3036
  • Fax: 310-388-5269

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: