Provider Demographics
NPI:1871181974
Name:DOUGLAS, MAXINE JEAN (LCSW)
Entity Type:Individual
Prefix:
First Name:MAXINE
Middle Name:JEAN
Last Name:DOUGLAS
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:MAXINE
Other - Middle Name:JEAN
Other - Last Name:ZANDIEH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MSW
Mailing Address - Street 1:10 PERIMETER SUMMIT BLVD NE UNIT 4408
Mailing Address - Street 2:
Mailing Address - City:BROOKHAVEN
Mailing Address - State:GA
Mailing Address - Zip Code:30319-1487
Mailing Address - Country:US
Mailing Address - Phone:404-468-3284
Mailing Address - Fax:678-309-1039
Practice Address - Street 1:10 PERIMETER SUMMIT BLVD NE UNIT 4408
Practice Address - Street 2:
Practice Address - City:BROOKHAVEN
Practice Address - State:GA
Practice Address - Zip Code:30319-1487
Practice Address - Country:US
Practice Address - Phone:404-468-3284
Practice Address - Fax:678-309-1039
Is Sole Proprietor?:Yes
Enumeration Date:2021-01-05
Last Update Date:2021-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GACSW0058401041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical