Healthcare Provider Details

I. General information

NPI: 1154946168
Provider Name (Legal Business Name): TYMATHIE DOUGLAS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/15/2020
Last Update Date: 11/16/2020
Certification Date: 11/16/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4287 FIVE OAKS DR
LANSING MI
48911-4214
US

IV. Provider business mailing address

5208 W SAGINAW HWY PO BOX #81096
LANSING MI
48917
US

V. Phone/Fax

Practice location:
  • Phone: 517-882-4000
  • Fax:
Mailing address:
  • Phone: 317-643-1014
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: