Healthcare Provider Details

I. General information

NPI: 1124946017
Provider Name (Legal Business Name): CARLA ANN DOUGLASS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/08/2026
Last Update Date: 07/08/2026
Certification Date: 07/08/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2010 OLD GREENBRIER RD STE B
CHESAPEAKE VA
23320-2619
US

IV. Provider business mailing address

2010 OLD GREENBRIER RD STE B
CHESAPEAKE VA
23320-2619
US

V. Phone/Fax

Practice location:
  • Phone: 757-702-3206
  • Fax: 757-702-3261
Mailing address:
  • Phone: 757-702-3206
  • Fax: 757-702-3261

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number6362010266
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: