Provider Demographics
NPI:1548381684
Name:DOUGLAS, ELLEN KAY (PHD)
Entity Type:Individual
Prefix:DR
First Name:ELLEN
Middle Name:KAY
Last Name:DOUGLAS
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:785 E BROAD ST
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43205-1013
Mailing Address - Country:US
Mailing Address - Phone:614-621-3673
Mailing Address - Fax:614-621-9508
Practice Address - Street 1:785 E BROAD ST
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43205-1013
Practice Address - Country:US
Practice Address - Phone:614-621-3673
Practice Address - Fax:614-621-9508
Is Sole Proprietor?:No
Enumeration Date:2007-04-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH3997103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OHDOCP06131Medicaid
CP06131Medicare ID - Type Unspecified
OHDOCP06131Medicaid