Provider Demographics
NPI:1659401107
Name:DOUGLAS, RICK D (LCSW)
Entity Type:Individual
Prefix:
First Name:RICK
Middle Name:D
Last Name:DOUGLAS
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4411 KINSEY DR
Mailing Address - Street 2:APT. 905
Mailing Address - City:TYLER
Mailing Address - State:TX
Mailing Address - Zip Code:75703-1015
Mailing Address - Country:US
Mailing Address - Phone:903-273-2642
Mailing Address - Fax:
Practice Address - Street 1:4411 KINSEY DR
Practice Address - Street 2:APT. 905
Practice Address - City:TYLER
Practice Address - State:TX
Practice Address - Zip Code:75703-1015
Practice Address - Country:US
Practice Address - Phone:903-273-2642
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-06
Last Update Date:2012-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX214381041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX040460001Medicaid
TX87039QOtherBLUE CROSS BLUE SHIELD