Healthcare Provider Details

I. General information

NPI: 1396155909
Provider Name (Legal Business Name): DOUGLAS WHITE
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/05/2014
Last Update Date: 05/05/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1305 TACOMA AVE S 305
TACOMA WA
98402-1903
US

IV. Provider business mailing address

1712 118TH ST S
TACOMA WA
98444-2416
US

V. Phone/Fax

Practice location:
  • Phone: 253-396-5800
  • Fax:
Mailing address:
  • Phone: 253-359-2613
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License NumberCG 60264112
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: