1356378921 NPI number — THERESSE ELIZABETH GIBBS DOUGLASS

Table of content: (NPI 1356378921)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1356378921 NPI number — THERESSE ELIZABETH GIBBS DOUGLASS

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
THERESSE ELIZABETH GIBBS DOUGLASS
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
ABOUT GETTING BETTER
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1356378921
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/14/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
6863 EAGLE HARBOR DR NE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BAINBRIDGE ISLAND
Provider Business Mailing Address State Name:
WA
Provider Business Mailing Address Postal Code:
98110-3103
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
206-780-3401
Provider Business Mailing Address Fax Number:
206-238-9777

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
6863 EAGLE HARBOR DR NE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BAINBRIDGE ISLAND
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98110-3103
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
206-780-3401
Provider Business Practice Location Address Fax Number:
206-238-9777
Provider Enumeration Date:
06/27/2006

Additional Information

Authorized Official

Authorized Official Last Name:
DOUGLASS
Authorized Official First Name:
THERESSE (TERRY)
Authorized Official Middle Name:
ELIZABETH
Authorized Official Title or Position:
SOLE PROPRIETOR
Authorized Official Telephone Number:
206-780-3401

Provider Taxonomy Codes

  • Taxonomy code: 363LP0808X , with the licence number:  AP30000194 , registered in the state of WA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 9605122 , issued by the state of ( WA ) . This identifiers is of the category "MEDICAID".




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