Provider Demographics
NPI:1730605825
Name:DOUGLAS, DALLY NICOLE (MS, RBT)
Entity type:Individual
Prefix:
First Name:DALLY
Middle Name:NICOLE
Last Name:DOUGLAS
Suffix:
Gender:F
Credentials:MS, RBT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4313 RIVER GATE LN
Mailing Address - Street 2:
Mailing Address - City:LITTLE RIVER
Mailing Address - State:SC
Mailing Address - Zip Code:29566-6828
Mailing Address - Country:US
Mailing Address - Phone:910-545-8353
Mailing Address - Fax:
Practice Address - Street 1:4313 RIVER GATE LN
Practice Address - Street 2:
Practice Address - City:LITTLE RIVER
Practice Address - State:SC
Practice Address - Zip Code:29566-6828
Practice Address - Country:US
Practice Address - Phone:910-545-8353
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-08-21
Last Update Date:2024-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor