Provider Demographics
NPI:1265474381
Name:DOUGLAS, MARCIA N (LCSW R)
Entity Type:Individual
Prefix:
First Name:MARCIA
Middle Name:N
Last Name:DOUGLAS
Suffix:
Gender:F
Credentials:LCSW R
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:272 S LHOMMEDIEU ST
Mailing Address - Street 2:
Mailing Address - City:MONTOUR FALLS
Mailing Address - State:NY
Mailing Address - Zip Code:14865-9786
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:106 S PERRY ST
Practice Address - Street 2:STE 4
Practice Address - City:WATKINS GLEN
Practice Address - State:NY
Practice Address - Zip Code:14891-1615
Practice Address - Country:US
Practice Address - Phone:607-535-8282
Practice Address - Fax:607-535-8284
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-06-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY052112101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY07300052112LIMedicaid
NY07300052112LIMedicaid
NYDD3113Medicare ID - Type Unspecified