Provider Demographics
NPI:1124366505
Name:DOUGLAS, R KEVIN (LCSW CASAC)
Entity Type:Individual
Prefix:
First Name:R
Middle Name:KEVIN
Last Name:DOUGLAS
Suffix:
Gender:M
Credentials:LCSW CASAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1073 MAIN ST STE 202A
Mailing Address - Street 2:
Mailing Address - City:FISHKILL
Mailing Address - State:NY
Mailing Address - Zip Code:12524-3513
Mailing Address - Country:US
Mailing Address - Phone:914-475-4083
Mailing Address - Fax:
Practice Address - Street 1:1073 MAIN ST STE 202A
Practice Address - Street 2:
Practice Address - City:FISHKILL
Practice Address - State:NY
Practice Address - Zip Code:12524-3513
Practice Address - Country:US
Practice Address - Phone:914-475-4083
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-01-20
Last Update Date:2013-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY73 0801021041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical