Provider Demographics
NPI:1790278000
Name:DOUGOUD, MIRANDA (MSW, LCSW)
Entity Type:Individual
Prefix:
First Name:MIRANDA
Middle Name:
Last Name:DOUGOUD
Suffix:
Gender:F
Credentials:MSW, LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1158 LEXINGTON RD
Mailing Address - Street 2:
Mailing Address - City:GEORGETOWN
Mailing Address - State:KY
Mailing Address - Zip Code:40324-9330
Mailing Address - Country:US
Mailing Address - Phone:502-462-7188
Mailing Address - Fax:
Practice Address - Street 1:1158 LEXINGTON RD
Practice Address - Street 2:
Practice Address - City:GEORGETOWN
Practice Address - State:KY
Practice Address - Zip Code:40324-9330
Practice Address - Country:US
Practice Address - Phone:502-462-7188
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-06-11
Last Update Date:2023-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY1041C0700X, 1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY1790731081Medicaid