MEDICARE: DR. KAREN YVETTE DOUGLASS PSY.D

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	103TC0700X	Clinical Psychologist	20042051A	IN
2	103TC0700X	Clinical Psychologist		IL

General Provider Information

NPI Number	:	1215940069
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. KAREN YVETTE DOUGLASS PSY.D

Provider Business Mailing Address
First Line	:	7712 S WABASH AVE
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60619-2321
Country	:	US
Telephone Number	:	773-487-0515
Fax Number	:

Provider Business Practice Location Address
First Line	:	132 E 79TH ST
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60619-2302
Country	:	US
Telephone Number	:	773-487-0515
Fax Number	:

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

Provider Enumeration Date	:	08/14/2006
Last Update Date	:	11/05/2021

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