Provider Demographics
NPI:1942388269
Name:DOUGLAS, MITCHELL (LCSW)
Entity Type:Individual
Prefix:
First Name:MITCHELL
Middle Name:
Last Name:DOUGLAS
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 1:150 W 96TH ST APT 4D
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10025-6443
Mailing Address - Country:US
Mailing Address - Phone:646-499-0936
Mailing Address - Fax:
Practice Address - Street 1:11 TAMARACK CIR
Practice Address - Street 2:
Practice Address - City:SKILLMAN
Practice Address - State:NJ
Practice Address - Zip Code:08558-2019
Practice Address - Country:US
Practice Address - Phone:609-279-1339
Practice Address - Fax:609-279-1359
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-02
Last Update Date:2023-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJSC048246001041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical