Provider Demographics
NPI:1679761290
Name:DOUGLASS, KATHLEEN M (MA, LCPC)
Entity Type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:M
Last Name:DOUGLASS
Suffix:
Gender:F
Credentials:MA, LCPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5325 COLUMBIA RD
Mailing Address - Street 2:APT. L
Mailing Address - City:COLUMBIA
Mailing Address - State:MD
Mailing Address - Zip Code:21044-5518
Mailing Address - Country:US
Mailing Address - Phone:301-821-6931
Mailing Address - Fax:
Practice Address - Street 1:5560 STERRETT PL
Practice Address - Street 2:SUITE 201
Practice Address - City:COLUMBIA
Practice Address - State:MD
Practice Address - Zip Code:21044-2601
Practice Address - Country:US
Practice Address - Phone:410-955-5555
Practice Address - Fax:410-995-5556
Is Sole Proprietor?:Yes
Enumeration Date:2007-10-09
Last Update Date:2007-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDLC2341101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional