Active NPI
Robert Derrick Douglas, ST
- Speech-Language Pathologist
- Nacogdoches, TX
National Provider Identifier
1104442508
On this page
Key facts
NPPES NPI Registry- Primary specialty
- Speech-Language Pathologist
- License
- 112439
- Practice address
- 421 N Fredonia St
Nacogdoches, TX 75961-5010 - Phone
- (936) 569-3150
- NPI assigned
- Jun 22, 2020
- Sex
- Male
- Sole proprietor
- No
NPPES NPI Registry
Registry information is reported by the provider to CMS and is not verified. About this source
Specialties & licenses 1
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Speech-Language Pathologist | 235Z00000X | 112439 | TX | Primary |
Addresses
Primary practice location
421 N Fredonia St
Nacogdoches, TX 75961-5010
Mailing address
4632 NE Stallings Dr
Nacogdoches, TX 75965-1620
Phone (936) 569-3150
Medicare participation
Medicare enrollment files- Medicare fee-for-service enrollment
- Not listed in the public Medicare enrollment file
National Provider Directory
National Provider Directory- Medicare enrollment (NPD)
- Not enrolled
State licenses
| License | State | Type | Specialty |
|---|---|---|---|
| 112439 | TX | MD | Speech-Language Pathologist |
NPI Registry JSON
The complete NPPES record for this NPI in the NPI Registry API format.
{
"created_epoch": "1592784000000",
"enumeration_type": "NPI-1",
"last_updated_epoch": "1739232000000",
"number": "1104442508",
"addresses": [
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "MAILING",
"address_type": "DOM",
"address_1": "4632 NE STALLINGS DR",
"city": "NACOGDOCHES",
"state": "TX",
"postal_code": "759651620",
"telephone_number": "936-569-3150"
},
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "LOCATION",
"address_type": "DOM",
"address_1": "421 N FREDONIA ST",
"city": "NACOGDOCHES",
"state": "TX",
"postal_code": "759615010",
"telephone_number": "936-569-3150"
}
],
"practiceLocations": [],
"basic": {
"last_name": "DOUGLAS",
"first_name": "ROBERT",
"middle_name": "DERRICK",
"name_prefix": "Mr.",
"credential": "ST",
"sole_proprietor": "NO",
"sex": "M",
"enumeration_date": "2020-06-22",
"last_updated": "2025-02-11",
"certification_date": "2025-02-11",
"status": "A"
},
"taxonomies": [
{
"code": "235Z00000X",
"taxonomy_group": "",
"desc": "Speech-Language Pathologist",
"state": "TX",
"license": "112439",
"primary": true
}
],
"identifiers": [],
"endpoints": [],
"other_names": []
}Other providers in Nacogdoches, TX
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Feb 11, 2025; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.