Healthcare Provider Details

I. General information

NPI: 1255220166
Provider Name (Legal Business Name): DEIANIERA DOUGLAS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/02/2025
Last Update Date: 07/02/2025
Certification Date: 07/02/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6317 N 48TH ST
OMAHA NE
68104-1361
US

IV. Provider business mailing address

6317 N 48TH ST
OMAHA NE
68104-1361
US

V. Phone/Fax

Practice location:
  • Phone: 402-594-9421
  • Fax:
Mailing address:
  • Phone: 402-594-9421
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YS0200X
TaxonomySchool Counselor
License Number1234
License Number StateNE

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: