Provider Demographics
NPI:1952631509
Name:MCDOUGAL, COLLEEN (LSW)
Entity Type:Individual
Prefix:
First Name:COLLEEN
Middle Name:
Last Name:MCDOUGAL
Suffix:
Gender:F
Credentials:LSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:899 RIVERSIDE ST
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:ME
Mailing Address - Zip Code:04103-1070
Mailing Address - Country:US
Mailing Address - Phone:207-871-1200
Mailing Address - Fax:207-871-1232
Practice Address - Street 1:3 HARRISON ST
Practice Address - Street 2:
Practice Address - City:SPRINGVALE
Practice Address - State:ME
Practice Address - Zip Code:04083-1010
Practice Address - Country:US
Practice Address - Phone:207-651-5335
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-01-04
Last Update Date:2010-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MELS12267104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker