Healthcare Provider Details

I. General information

NPI: 1417814187
Provider Name (Legal Business Name): MR. WILLARD DOUGLAS DEROUEN JR.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/06/2026
Last Update Date: 05/06/2026
Certification Date: 05/06/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

910 W BOONE AVE
SPOKANE WA
99201-5029
US

IV. Provider business mailing address

7440 W MARGINAL WAY S
SEATTLE WA
98108-4141
US

V. Phone/Fax

Practice location:
  • Phone: 206-665-1386
  • Fax:
Mailing address:
  • Phone: 206-665-1386
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code175T00000X
TaxonomyPeer Specialist
License Number
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: