Provider Demographics
NPI:1336439306
Name:DOUGLAS, ELIZABETH A (MA, LADC, LPCC)
Entity Type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:A
Last Name:DOUGLAS
Suffix:
Gender:F
Credentials:MA, LADC, LPCC
Other - Prefix:
Other - First Name:ELIZABETH
Other - Middle Name:A
Other - Last Name:MYHRE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:BA, LADC
Mailing Address - Street 1:11660 ROUND LAKE BLVD NW
Mailing Address - Street 2:
Mailing Address - City:COON RAPIDS
Mailing Address - State:MN
Mailing Address - Zip Code:55433-2638
Mailing Address - Country:US
Mailing Address - Phone:763-439-4984
Mailing Address - Fax:763-767-0912
Practice Address - Street 1:11660 ROUND LAKE BLVD NW
Practice Address - Street 2:
Practice Address - City:COON RAPIDS
Practice Address - State:MN
Practice Address - Zip Code:55433-2638
Practice Address - Country:US
Practice Address - Phone:763-439-4984
Practice Address - Fax:763-767-0912
Is Sole Proprietor?:No
Enumeration Date:2011-04-12
Last Update Date:2023-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN302188101YA0400X
MN2409101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)