Provider Demographics
NPI:1679105506
Name:DOUGLAS, NEBROJAMOR
Entity type:Individual
Prefix:
First Name:NEBROJAMOR
Middle Name:
Last Name:DOUGLAS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5 EDGEWATER CIR
Mailing Address - Street 2:
Mailing Address - City:DANBURY
Mailing Address - State:CT
Mailing Address - Zip Code:06810-6273
Mailing Address - Country:US
Mailing Address - Phone:917-856-4684
Mailing Address - Fax:
Practice Address - Street 1:101 SHOREVIEW DR
Practice Address - Street 2:
Practice Address - City:YONKERS
Practice Address - State:NY
Practice Address - Zip Code:10710-1324
Practice Address - Country:US
Practice Address - Phone:914-318-5538
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-02-08
Last Update Date:2020-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician