Provider Demographics
NPI:1376093344
Name:DOUGLAS, CONSTANCE (LCSW)
Entity Type:Individual
Prefix:
First Name:CONSTANCE
Middle Name:
Last Name:DOUGLAS
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11 W PROSPECT AVE FL 4
Mailing Address - Street 2:C/O WJCS
Mailing Address - City:MOUNT VERNON
Mailing Address - State:NY
Mailing Address - Zip Code:10550-2017
Mailing Address - Country:US
Mailing Address - Phone:914-668-8938
Mailing Address - Fax:914-668-2545
Practice Address - Street 1:11 W PROSPECT AVE FL 4
Practice Address - Street 2:C/O WJCS
Practice Address - City:MOUNT VERNON
Practice Address - State:NY
Practice Address - Zip Code:10550-2017
Practice Address - Country:US
Practice Address - Phone:914-668-8938
Practice Address - Fax:914-668-2545
Is Sole Proprietor?:No
Enumeration Date:2016-10-13
Last Update Date:2016-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY071290104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker