Basic Information
| Provider Information | |||||||||
| NPI: | 1407317704 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DOUGLAS | ||||||||
| FirstName: | RAYMOND | ||||||||
| MiddleName: | EDWARD | ||||||||
| NamePrefix: | MR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | RAS | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4510 PERALTA BLVD STE 1 | ||||||||
| Address2: | |||||||||
| City: | FREMONT | ||||||||
| State: | CA | ||||||||
| PostalCode: | 945365755 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5107133202 | ||||||||
| FaxNumber: | 5107130684 | ||||||||
| Practice Location | |||||||||
| Address1: | 37437 GLENMOOR DR | ||||||||
| Address2: | |||||||||
| City: | FREMONT | ||||||||
| State: | CA | ||||||||
| PostalCode: | 945365731 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5107133200 | ||||||||
| FaxNumber: | 5107130684 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/28/2019 | ||||||||
| LastUpdateDate: | 09/08/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 09/08/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YA0400X | R1326931018 | CA | N | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) | 101YA0400X | A058430920 | CA | Y | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) |
ID Information
| ID | Type | State | Issuer | Description | A058430920 | 01 | CA | CCAPP | OTHER |