Provider Demographics
NPI:1922209485
Name:VINCENT, DOUGLAS J (LCSW)
Entity Type:Individual
Prefix:MR
First Name:DOUGLAS
Middle Name:J
Last Name:VINCENT
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 723
Mailing Address - Street 2:
Mailing Address - City:CLIFTON PARK
Mailing Address - State:NY
Mailing Address - Zip Code:12065-0723
Mailing Address - Country:US
Mailing Address - Phone:518-928-4315
Mailing Address - Fax:518-877-5302
Practice Address - Street 1:2023 ROUTE 9
Practice Address - Street 2:
Practice Address - City:ROUND LAKE
Practice Address - State:NY
Practice Address - Zip Code:12151-1701
Practice Address - Country:US
Practice Address - Phone:518-877-5301
Practice Address - Fax:518-877-5302
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-30
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYR053428-11041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY139944Medicare UPIN
NY000491519003Medicare UPIN