1215940069 NPI number — DR. KAREN YVETTE DOUGLASS PSY.D

Table of content: DR. KAREN YVETTE DOUGLASS PSY.D (NPI 1215940069)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1215940069 NPI number — DR. KAREN YVETTE DOUGLASS PSY.D

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
DOUGLASS
Provider First Name:
KAREN
Provider Middle Name:
YVETTE
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
PSY.D
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
ROLAND
Provider Other First Name:
KAR3N
Provider Other Middle Name:
YVETTE
Provider Other Name Prefix Text:
MS.
Provider Other Name Suffix Text:
Provider Other Credential Text:
PSYD
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1215940069
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
11/05/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

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

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
132 E 79TH ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CHICAGO
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
60619-2302
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
773-487-0515
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
08/14/2006

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 103TC0700X , with the licence number:  20042051A , registered in the state of IN ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 103TC0700X , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)