Provider Demographics
NPI:1588204051
Name:DOUGLAS, ACACIA (LMFT)
Entity Type:Individual
Prefix:
First Name:ACACIA
Middle Name:
Last Name:DOUGLAS
Suffix:
Gender:F
Credentials:LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:521 FRANKLIN AVE
Mailing Address - Street 2:
Mailing Address - City:TROY
Mailing Address - State:IL
Mailing Address - Zip Code:62294-2105
Mailing Address - Country:US
Mailing Address - Phone:618-553-4317
Mailing Address - Fax:
Practice Address - Street 1:7710 CARONDELET AVE STE 304
Practice Address - Street 2:
Practice Address - City:CLAYTON
Practice Address - State:MO
Practice Address - Zip Code:63105-3319
Practice Address - Country:US
Practice Address - Phone:314-725-1515
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-01-13
Last Update Date:2022-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YM0800X
MO2020022446106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health