Provider Demographics
NPI:1700412806
Name:DOUGLAS, MARKYSHA
Entity Type:Individual
Prefix:
First Name:MARKYSHA
Middle Name:
Last Name:DOUGLAS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:98 EAST AVE
Mailing Address - Street 2:
Mailing Address - City:NORWALK
Mailing Address - State:CT
Mailing Address - Zip Code:06851-5029
Mailing Address - Country:US
Mailing Address - Phone:203-580-6660
Mailing Address - Fax:657-999-7622
Practice Address - Street 1:98 EAST AVE
Practice Address - Street 2:
Practice Address - City:NORWALK
Practice Address - State:CT
Practice Address - Zip Code:06851-5029
Practice Address - Country:US
Practice Address - Phone:203-580-6660
Practice Address - Fax:657-999-7622
Is Sole Proprietor?:Yes
Enumeration Date:2020-03-20
Last Update Date:2023-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT131111041C0700X
251B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No251B00000XAgenciesCase Management