MEDICARE: JAMES DOUGLAS JR. BA

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	222Q00000X	Developmental Therapist		FL
2	106S00000X	Behavior Technician		FL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1184162927
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JAMES DOUGLAS JR. BA

Provider Business Mailing Address
First Line	:	116 S LONGPORT CIR UNIT C116C
Second Line	:
City	:	DELRAY BEACH
State	:	FL
Zip	:	33444-3416
Country	:	US
Telephone Number	:	304-203-4551
Fax Number	:

Provider Business Practice Location Address
First Line	:	7138 S MILITARY TRL
Second Line	:
City	:	LAKE WORTH
State	:	FL
Zip	:	33463-7812
Country	:	US
Telephone Number	:	561-542-7795
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	02/01/2017
Last Update Date	:	02/05/2020

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