MEDICARE: WENDY ANNE DOUGLAS 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

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	:	1205163300
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	WENDY ANNE DOUGLAS BA

Provider Business Mailing Address
First Line	:	9685 BAY HARBOR CIR APT 201
Second Line	:
City	:	FORT MYERS
State	:	FL
Zip	:	33919-5724
Country	:	US
Telephone Number	:	239-440-9802
Fax Number	:

Provider Business Practice Location Address
First Line	:	9685 BAY HARBOR CIR APT 201
Second Line	:
City	:	FORT MYERS
State	:	FL
Zip	:	33919-5724
Country	:	US
Telephone Number	:	239-440-9802
Fax Number	:

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

Provider Enumeration Date	:	11/10/2009
Last Update Date	:	05/18/2022

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