Provider Demographics
NPI:1659897080
Name:DOUGLAS, VERONICA JEAN (LICSW)
Entity Type:Individual
Prefix:
First Name:VERONICA
Middle Name:JEAN
Last Name:DOUGLAS
Suffix:
Gender:F
Credentials:LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:162 PEARL ST
Mailing Address - Street 2:
Mailing Address - City:SAINT ALBANS
Mailing Address - State:VT
Mailing Address - Zip Code:05478-2139
Mailing Address - Country:US
Mailing Address - Phone:802-999-3208
Mailing Address - Fax:
Practice Address - Street 1:228 N MAIN ST
Practice Address - Street 2:
Practice Address - City:SAINT ALBANS
Practice Address - State:VT
Practice Address - Zip Code:05478-1588
Practice Address - Country:US
Practice Address - Phone:802-999-3208
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-08-17
Last Update Date:2018-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT151.0128937101YA0400X
VT089.01331011041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Single Specialty