Provider Demographics
NPI:1932112935
Name:DOUGLAS, LINDA S (LICDC-CS, LISW-S)
Entity Type:Individual
Prefix:
First Name:LINDA
Middle Name:S
Last Name:DOUGLAS
Suffix:
Gender:F
Credentials:LICDC-CS, LISW-S
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4600 MONTGOMERY RD STE 400
Mailing Address - Street 2:
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45212-2600
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4483 US ROUTE 42
Practice Address - Street 2:
Practice Address - City:MASON
Practice Address - State:OH
Practice Address - Zip Code:45040-1934
Practice Address - Country:US
Practice Address - Phone:513-834-7063
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-14
Last Update Date:2024-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHLICDC.081195101YA0400X
OHI 00303791041C0700X
OHI.0030379-SUPV104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
OHI 0030379OtherLISW