Provider Demographics
NPI:1730973330
Name:DOUGLAS, ROBERT (CSA CERTIFICATION)
Entity type:Individual
Prefix:
First Name:ROBERT
Middle Name:
Last Name:DOUGLAS
Suffix:
Gender:
Credentials:CSA CERTIFICATION
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11900 BOYDTON CT
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40245-1807
Mailing Address - Country:US
Mailing Address - Phone:502-579-3236
Mailing Address - Fax:
Practice Address - Street 1:3721 RIVER PARK DR
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40211-3024
Practice Address - Country:US
Practice Address - Phone:502-609-0034
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-04-08
Last Update Date:2025-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health