Provider Demographics
NPI:1497840672
Name:DOUGLAS, PATRICIA A (LCSW)
Entity Type:Individual
Prefix:MS
First Name:PATRICIA
Middle Name:A
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 1:66 OAKWOOD DR
Mailing Address - Street 2:
Mailing Address - City:MEDFORD
Mailing Address - State:NJ
Mailing Address - Zip Code:08055-8824
Mailing Address - Country:US
Mailing Address - Phone:732-493-8080
Mailing Address - Fax:732-493-8810
Practice Address - Street 1:931 W PARK AVE
Practice Address - Street 2:
Practice Address - City:OCEAN
Practice Address - State:NJ
Practice Address - Zip Code:07712-7207
Practice Address - Country:US
Practice Address - Phone:732-493-8080
Practice Address - Fax:732-493-8810
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ44SC005922001041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ44SC00592200Medicare ID - Type Unspecified