Provider Demographics
NPI:1508475062
Name:DOUGLAS, MARK (LCSW)
Entity Type:Individual
Prefix:MR
First Name:MARK
Middle Name:
Last Name:DOUGLAS
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:178 FINN CIR
Mailing Address - Street 2:
Mailing Address - City:SAVANNAH
Mailing Address - State:GA
Mailing Address - Zip Code:31419-8408
Mailing Address - Country:US
Mailing Address - Phone:912-308-6735
Mailing Address - Fax:
Practice Address - Street 1:303 FRASER DR
Practice Address - Street 2:
Practice Address - City:HINESVILLE
Practice Address - State:GA
Practice Address - Zip Code:31313-3712
Practice Address - Country:US
Practice Address - Phone:912-877-2227
Practice Address - Fax:912-877-2332
Is Sole Proprietor?:No
Enumeration Date:2020-07-30
Last Update Date:2020-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GACSW007151104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker