Provider Demographics
NPI:1427557438
Name:MACDOUGALL, KATHRYN CLARK
Entity Type:Individual
Prefix:
First Name:KATHRYN
Middle Name:CLARK
Last Name:MACDOUGALL
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:305 MURDOCK RD
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21212-1826
Mailing Address - Country:US
Mailing Address - Phone:443-900-3102
Mailing Address - Fax:
Practice Address - Street 1:5022 CAMPBELL BLVD STE L
Practice Address - Street 2:
Practice Address - City:NOTTINGHAM
Practice Address - State:MD
Practice Address - Zip Code:21236-4969
Practice Address - Country:US
Practice Address - Phone:443-442-1568
Practice Address - Fax:443-442-1569
Is Sole Proprietor?:Yes
Enumeration Date:2018-02-05
Last Update Date:2018-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD19309104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker