Healthcare Provider Details

I. General information

NPI: 1407229248
Provider Name (Legal Business Name): ROY DOUGLAS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/02/2015
Last Update Date: 01/09/2024
Certification Date: 04/13/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1235 MCHERNEY A AND B
MODESTO CA
95350-9411
US

IV. Provider business mailing address

1212 N CALIFORNIA ST
STOCKTON CA
95202-1552
US

V. Phone/Fax

Practice location:
  • Phone: 209-507-5559
  • Fax:
Mailing address:
  • Phone: 209-468-8686
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number1041C0700X.
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: