Provider Demographics
NPI:1558612036
Name:DOUGLAS, ELLEN (LPC)
Entity Type:Individual
Prefix:MRS
First Name:ELLEN
Middle Name:
Last Name:DOUGLAS
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:706 MONROE DR
Mailing Address - Street 2:
Mailing Address - City:RALEIGH
Mailing Address - State:NC
Mailing Address - Zip Code:27604-2357
Mailing Address - Country:US
Mailing Address - Phone:704-830-7020
Mailing Address - Fax:
Practice Address - Street 1:901 PAVERSTONE DR
Practice Address - Street 2:
Practice Address - City:RALEIGH
Practice Address - State:NC
Practice Address - Zip Code:27615-4710
Practice Address - Country:US
Practice Address - Phone:919-818-4284
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-09-25
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC8577101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NCP99260Medicaid