Provider Demographics
NPI:1083045710
Name:DOUGLAS, MARVIN HUGH
Entity Type:Individual
Prefix:DR
First Name:MARVIN
Middle Name:HUGH
Last Name:DOUGLAS
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 1:34 LINCOLN TER
Mailing Address - Street 2:
Mailing Address - City:BLOOMFIELD
Mailing Address - State:CT
Mailing Address - Zip Code:06002-3125
Mailing Address - Country:US
Mailing Address - Phone:860-830-9333
Mailing Address - Fax:860-761-7928
Practice Address - Street 1:330 MARKET ST
Practice Address - Street 2:
Practice Address - City:HARTFORD
Practice Address - State:CT
Practice Address - Zip Code:06120-2901
Practice Address - Country:US
Practice Address - Phone:860-490-8864
Practice Address - Fax:860-761-7928
Is Sole Proprietor?:Yes
Enumeration Date:2013-12-05
Last Update Date:2013-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT000090101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)