Provider Demographics
NPI:1760686299
Name:ROSCOE L. DOUGLAS, PH.D., P.A.
Entity type:Organization
Organization Name:ROSCOE L. DOUGLAS, PH.D., P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLINICAL PSYCHOLOGIST
Authorized Official - Prefix:
Authorized Official - First Name:ROSCOE
Authorized Official - Middle Name:LORMER
Authorized Official - Last Name:DOUGLAS
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:601-483-8370
Mailing Address - Street 1:PO BOX 3545
Mailing Address - Street 2:
Mailing Address - City:MERIDIAN
Mailing Address - State:MS
Mailing Address - Zip Code:39303-3545
Mailing Address - Country:US
Mailing Address - Phone:601-483-8370
Mailing Address - Fax:
Practice Address - Street 1:1207 WHITE OAK DR
Practice Address - Street 2:
Practice Address - City:MERIDIAN
Practice Address - State:MS
Practice Address - Zip Code:39305-1902
Practice Address - Country:US
Practice Address - Phone:601-483-8370
Practice Address - Fax:601-482-4248
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-11
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS139103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00017960Medicaid
MS1740494434OtherNPI INDIV PROV NUMBER