Provider Demographics
NPI:1457475089
Name:DOUGLAS, DAVID STUART (MSW, LICSW)
Entity Type:Individual
Prefix:MR
First Name:DAVID
Middle Name:STUART
Last Name:DOUGLAS
Suffix:
Gender:M
Credentials:MSW, LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:279 MASSACHUSETTS AVE
Mailing Address - Street 2:
Mailing Address - City:ARLINGTON
Mailing Address - State:MA
Mailing Address - Zip Code:02474-8302
Mailing Address - Country:US
Mailing Address - Phone:617-571-5194
Mailing Address - Fax:
Practice Address - Street 1:279 MASSACHUSETTS AVE
Practice Address - Street 2:
Practice Address - City:ARLINGTON
Practice Address - State:MA
Practice Address - Zip Code:02474-8302
Practice Address - Country:US
Practice Address - Phone:781-777-1726
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA10184001041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAPO5220OtherBLUE CROSS BLUE SHIELD
MADO P22396Medicare ID - Type UnspecifiedMEDICARE PROVIDER ID