MEDICARE: KIM DOUGLAS

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	225X00000X	Occupational Therapist	OT10201	FL

General Provider Information

NPI Number	:	1548785249
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KIM DOUGLAS

Provider Business Mailing Address
First Line	:	922 E BOBE ST
Second Line	:
City	:	PENSACOLA
State	:	FL
Zip	:	32503-3962
Country	:	US
Telephone Number	:	850-741-6715
Fax Number	:	850-204-0489

Provider Business Practice Location Address
First Line	:	7830 PINE FOREST RD
Second Line	:	COTTAGE A
City	:	PENSACOLA
State	:	FL
Zip	:	32526-8404
Country	:	US
Telephone Number	:	850-741-6715
Fax Number	:	850-204-0489

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

Provider Enumeration Date	:	08/03/2017
Last Update Date	:	07/13/2023

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Directions to “ KIM DOUGLAS ” Practice Location

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