Provider Demographics
NPI:1023706041
Name:DOUGLAS, DEREK (RPSGT, CNA, FCMT, BS)
Entity type:Individual
Prefix:
First Name:DEREK
Middle Name:
Last Name:DOUGLAS
Suffix:
Gender:M
Credentials:RPSGT, CNA, FCMT, BS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4 WILLOW LN
Mailing Address - Street 2:
Mailing Address - City:GUNNISON
Mailing Address - State:CO
Mailing Address - Zip Code:81230-9762
Mailing Address - Country:US
Mailing Address - Phone:970-746-6387
Mailing Address - Fax:970-832-9287
Practice Address - Street 1:523 N PINE ST.
Practice Address - Street 2:
Practice Address - City:GUNNISON
Practice Address - State:CO
Practice Address - Zip Code:81230-2615
Practice Address - Country:US
Practice Address - Phone:970-746-6387
Practice Address - Fax:970-832-9287
Is Sole Proprietor?:No
Enumeration Date:2023-04-27
Last Update Date:2023-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
171400000X, 247200000X, 374K00000X, 374K00000X, 261QC1500X
CONA.00764940374U00000X, 376K00000X, 374U00000X, 376K00000X
CO24531246Z00000X, 261QS1200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QS1200XAmbulatory Health Care FacilitiesClinic/CenterSleep Disorder Diagnostic
No171400000XOther Service ProvidersHealth & Wellness Coach
No247200000XTechnologists, Technicians & Other Technical Service ProvidersTechnician, Other
No374K00000XNursing Service Related ProvidersReligious Nonmedical Practitioner
No374U00000XNursing Service Related ProvidersHome Health Aide
No376K00000XNursing Service Related ProvidersNurse's Aide
Yes246Z00000XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, Other
No261QC1500XAmbulatory Health Care FacilitiesClinic/CenterCommunity Health