Individual
KELLY DOUGLAS
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
F
Contact information
Practice address
910 HILLSIDE DR, JEFFERSON, WI 53549-1823
(920) 650-0027
Mailing address
910 HILLSIDE DR, JEFFERSON, WI 53549-1823
(920) 650-0027
Taxonomy
Speciality
Code
Description
License number
State
320900000X
Intellectual and/or Developmental Disabilities Community Based Residential Treatment Facility
Primary
—
—
Other
Enumeration date
09/09/2024
Last updated
09/09/2024
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