Provider Demographics
NPI:1275829558
Name:DOUGLASS, SUSAN ELLEN (LICSW)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:ELLEN
Last Name:DOUGLASS
Suffix:
Gender:F
Credentials:LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:45 SUMMER ST
Mailing Address - Street 2:
Mailing Address - City:LEOMINSTER
Mailing Address - State:MA
Mailing Address - Zip Code:01453-3228
Mailing Address - Country:US
Mailing Address - Phone:508-421-4544
Mailing Address - Fax:
Practice Address - Street 1:72 JAQUES AVE
Practice Address - Street 2:
Practice Address - City:WORCESTER
Practice Address - State:MA
Practice Address - Zip Code:01610-2476
Practice Address - Country:US
Practice Address - Phone:508-860-1154
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-06-24
Last Update Date:2011-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA1163721041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical