Provider Demographics
NPI:1922102409
Name:DOUGLAS, KATHRYN ANNE (BCBA, LCPC, LPCC)
Entity Type:Individual
Prefix:
First Name:KATHRYN
Middle Name:ANNE
Last Name:DOUGLAS
Suffix:
Gender:F
Credentials:BCBA, LCPC, LPCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2909 SELKIRK LN
Mailing Address - Street 2:
Mailing Address - City:QUINCY
Mailing Address - State:IL
Mailing Address - Zip Code:62305-6525
Mailing Address - Country:US
Mailing Address - Phone:415-580-0239
Mailing Address - Fax:
Practice Address - Street 1:535 MAINE ST
Practice Address - Street 2:
Practice Address - City:QUINCY
Practice Address - State:IL
Practice Address - Zip Code:62301-3950
Practice Address - Country:US
Practice Address - Phone:217-577-2176
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-12
Last Update Date:2023-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101Y00000X
IL180007537101YP2500X
MO2009032566101YP2500X
CA13837101YP2500X
IL1-19-35663103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No101Y00000XBehavioral Health & Social Service ProvidersCounselor
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional