Provider Demographics
NPI:1962445387
Name:ESSEX, DOUG A (LCAC)
Entity Type:Individual
Prefix:
First Name:DOUG
Middle Name:A
Last Name:ESSEX
Suffix:
Gender:M
Credentials:LCAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:202 E MAIN ST
Mailing Address - Street 2:PO BOX 376
Mailing Address - City:LADOGA
Mailing Address - State:IN
Mailing Address - Zip Code:47954-9799
Mailing Address - Country:US
Mailing Address - Phone:765-942-2182
Mailing Address - Fax:
Practice Address - Street 1:610 MAIN STREET
Practice Address - Street 2:
Practice Address - City:LAFAYETTE
Practice Address - State:IN
Practice Address - Zip Code:47901
Practice Address - Country:US
Practice Address - Phone:765-423-2638
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-14
Last Update Date:2011-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101Y00000X
IN101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)