Provider Demographics
NPI:1861517310
Name:VADER, DOUGLAS
Entity type:Individual
Prefix:
First Name:DOUGLAS
Middle Name:
Last Name:VADER
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 1:1215 S MAIN ST
Mailing Address - Street 2:
Mailing Address - City:YREKA
Mailing Address - State:CA
Mailing Address - Zip Code:96097-3479
Mailing Address - Country:US
Mailing Address - Phone:530-841-4200
Mailing Address - Fax:
Practice Address - Street 1:1215 S MAIN ST
Practice Address - Street 2:
Practice Address - City:YREKA
Practice Address - State:CA
Practice Address - Zip Code:96097-3479
Practice Address - Country:US
Practice Address - Phone:530-841-4200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-20
Last Update Date:2008-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health