Provider Demographics
NPI:1609675370
Name:DOUGLAS, TERRANISHA
Entity type:Individual
Prefix:
First Name:TERRANISHA
Middle Name:
Last Name:DOUGLAS
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:18154 MARTIN AVE STE 1
Mailing Address - Street 2:
Mailing Address - City:HOMEWOOD
Mailing Address - State:IL
Mailing Address - Zip Code:60430-2155
Mailing Address - Country:US
Mailing Address - Phone:708-625-4836
Mailing Address - Fax:
Practice Address - Street 1:18154 MARTIN AVE STE 1
Practice Address - Street 2:
Practice Address - City:HOMEWOOD
Practice Address - State:IL
Practice Address - Zip Code:60430-2155
Practice Address - Country:US
Practice Address - Phone:708-625-4836
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-03-13
Last Update Date:2025-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician