Provider Demographics
NPI:1568738722
Name:DOUGLASS, ELISSA BETH (MSW, LISW)
Entity Type:Individual
Prefix:MS
First Name:ELISSA
Middle Name:BETH
Last Name:DOUGLASS
Suffix:
Gender:F
Credentials:MSW, LISW
Other - Prefix:MS
Other - First Name:ELISSA
Other - Middle Name:B
Other - Last Name:DOUGLASS
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LISW-S
Mailing Address - Street 1:726 WICK AVE
Mailing Address - Street 2:
Mailing Address - City:YOUNGSTOWN
Mailing Address - State:OH
Mailing Address - Zip Code:44505-2827
Mailing Address - Country:US
Mailing Address - Phone:330-747-9551
Mailing Address - Fax:330-884-6120
Practice Address - Street 1:7062 WEST BLVD UNIT 2
Practice Address - Street 2:
Practice Address - City:BOARDMAN
Practice Address - State:OH
Practice Address - Zip Code:44512-4301
Practice Address - Country:US
Practice Address - Phone:614-499-5131
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-03-31
Last Update Date:2020-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHI12000361041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical