Provider Demographics
NPI:1235780016
Name:DOUGLAS, EMERSON LEE (LISW)
Entity Type:Individual
Prefix:MR
First Name:EMERSON
Middle Name:LEE
Last Name:DOUGLAS
Suffix:
Gender:M
Credentials:LISW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9220 MENTOR AVE
Mailing Address - Street 2:
Mailing Address - City:MENTOR
Mailing Address - State:OH
Mailing Address - Zip Code:44060-6412
Mailing Address - Country:US
Mailing Address - Phone:440-354-9924
Mailing Address - Fax:833-209-8465
Practice Address - Street 1:30800 CHAGRIN BLVD
Practice Address - Street 2:
Practice Address - City:PEPPER PIKE
Practice Address - State:OH
Practice Address - Zip Code:44124-5925
Practice Address - Country:US
Practice Address - Phone:216-591-0324
Practice Address - Fax:216-591-1243
Is Sole Proprietor?:Yes
Enumeration Date:2019-09-24
Last Update Date:2020-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHI.20021461041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2864093Medicaid