Provider Demographics
NPI:1619544756
Name:DOUGLASS, GENNA (BCBA)
Entity type:Individual
Prefix:
First Name:GENNA
Middle Name:
Last Name:DOUGLASS
Suffix:
Gender:F
Credentials:BCBA
Other - Prefix:
Other - First Name:GENNA
Other - Middle Name:
Other - Last Name:THOMAS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1061 E SOUTHERN AVE
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46203
Mailing Address - Country:US
Mailing Address - Phone:317-914-3176
Mailing Address - Fax:844-742-6592
Practice Address - Street 1:1061 E SOUTHERN AVE
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46203
Practice Address - Country:US
Practice Address - Phone:463-701-0909
Practice Address - Fax:844-742-6592
Is Sole Proprietor?:No
Enumeration Date:2021-06-08
Last Update Date:2025-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN11621917103K00000X
1-23-69115103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst