Provider Demographics
NPI:1285649111
Name:DOUGLAS, KATHLEEN (MSW)
Entity Type:Individual
Prefix:MRS
First Name:KATHLEEN
Middle Name:
Last Name:DOUGLAS
Suffix:
Gender:F
Credentials:MSW
Other - Prefix:MS
Other - First Name:KATHLEEN
Other - Middle Name:
Other - Last Name:DOUGLAS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LCSW
Mailing Address - Street 1:323 MT PARNASSUS RD
Mailing Address - Street 2:
Mailing Address - City:EAST HADDAM
Mailing Address - State:CT
Mailing Address - Zip Code:06423
Mailing Address - Country:US
Mailing Address - Phone:860-873-3439
Mailing Address - Fax:860-873-3439
Practice Address - Street 1:FLEET & FAMILY SUPPORT CENTER
Practice Address - Street 2:BOX 93 NAVSUBASENLON
Practice Address - City:GROTON
Practice Address - State:CT
Practice Address - Zip Code:06349-5093
Practice Address - Country:US
Practice Address - Phone:860-694-4961
Practice Address - Fax:860-694-4018
Is Sole Proprietor?:No
Enumeration Date:2006-07-29
Last Update Date:2009-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT0065911041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT006591OtherLCSW