Healthcare Provider Details

I. General information

NPI: 1124533344
Provider Name (Legal Business Name): MRS. SELINA DOUGLASS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/11/2017
Last Update Date: 12/11/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

16999 MORRISON ST
SOUTHFIELD MI
48076-2016
US

IV. Provider business mailing address

16999 MORRISON ST
SOUTHFIELD MI
48076-2016
US

V. Phone/Fax

Practice location:
  • Phone: 248-875-0996
  • Fax:
Mailing address:
  • Phone: 248-875-0996
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TA0700X
TaxonomyAdult Development & Aging Psychologist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: