Provider Demographics
NPI:1548563620
Name:MCDOUGALL, CASEY LEE (PHD, LP)
Entity Type:Individual
Prefix:DR
First Name:CASEY
Middle Name:LEE
Last Name:MCDOUGALL
Suffix:
Gender:M
Credentials:PHD, LP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:BOX 497
Mailing Address - Street 2:HWY 1 AVE
Mailing Address - City:RED LAKE
Mailing Address - State:MN
Mailing Address - Zip Code:56671
Mailing Address - Country:US
Mailing Address - Phone:218-679-3912
Mailing Address - Fax:218-679-0181
Practice Address - Street 1:HWY 1 HOSPITAL DRIVE
Practice Address - Street 2:BOX 497
Practice Address - City:RED LAKE
Practice Address - State:MN
Practice Address - Zip Code:56671
Practice Address - Country:US
Practice Address - Phone:218-679-3912
Practice Address - Fax:218-679-0181
Is Sole Proprietor?:No
Enumeration Date:2010-12-13
Last Update Date:2012-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNLP 5341103TC0700X, 103T00000X, 103TC2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103T00000XBehavioral Health & Social Service ProvidersPsychologist
No103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & Adolescent
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN1508809765Medicaid
MNLP 5341OtherMN BOARD OF PSYCHOLOGY LICENSE #
MNLP 5341OtherMN BOARD OF PSYCHOLOGY LICENSE #
MN240206Medicare Oscar/Certification