Basic Information
| Provider Information | |||||||||
| NPI: | 1144978040 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DOUGLAS | ||||||||
| FirstName: | KIMBERLY | ||||||||
| MiddleName: | DESHAY | ||||||||
| NamePrefix: | |||||||||
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| Credential: | MA, MBC | ||||||||
| OtherOrganizationName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 6430 COURT RD BLDG A | ||||||||
| Address2: | |||||||||
| City: | HOUSTON | ||||||||
| State: | TX | ||||||||
| PostalCode: | 770534462 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8325391416 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 6430 COURT RD BLDG A | ||||||||
| Address2: | |||||||||
| City: | HOUSTON | ||||||||
| State: | TX | ||||||||
| PostalCode: | 770534462 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3253914168 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/10/2022 | ||||||||
| LastUpdateDate: | 03/15/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 03/15/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101Y00000X | N | Behavioral Health & Social Service Providers | Counselor | 251B00000X | N | Agencies | Case Management | 376K00000X | Y | Nursing Service Related Providers | Nurse's Aide |
No ID Information.