Provider Demographics
NPI:1447852017
Name:DOUGLASS, PHYLLIS (CAMTC# 56843)
Entity type:Individual
Prefix:
First Name:PHYLLIS
Middle Name:
Last Name:DOUGLASS
Suffix:
Gender:F
Credentials:CAMTC# 56843
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1901 CANOPY LN
Mailing Address - Street 2:
Mailing Address - City:LA VERNE
Mailing Address - State:CA
Mailing Address - Zip Code:91750-3514
Mailing Address - Country:US
Mailing Address - Phone:909-967-0246
Mailing Address - Fax:
Practice Address - Street 1:340 S GLENDORA AVE
Practice Address - Street 2:
Practice Address - City:GLENDORA
Practice Address - State:CA
Practice Address - Zip Code:91741-6255
Practice Address - Country:US
Practice Address - Phone:909-967-0246
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-11-10
Last Update Date:2020-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA56843225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist