Provider Demographics
NPI:1356172233
Name:DOUGLAS, MAYRA GARCIA (LSW)
Entity type:Individual
Prefix:
First Name:MAYRA
Middle Name:GARCIA
Last Name:DOUGLAS
Suffix:
Gender:F
Credentials:LSW
Other - Prefix:
Other - First Name:MAYRA
Other - Middle Name:
Other - Last Name:GARCIA RODRIGUEZ
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:301 S WALNUT LN
Mailing Address - Street 2:
Mailing Address - City:SCHAUMBURG
Mailing Address - State:IL
Mailing Address - Zip Code:60193-1004
Mailing Address - Country:US
Mailing Address - Phone:630-812-8816
Mailing Address - Fax:
Practice Address - Street 1:3100 W HIGGINS RD STE 190
Practice Address - Street 2:
Practice Address - City:HOFFMAN ESTATES
Practice Address - State:IL
Practice Address - Zip Code:60169-7252
Practice Address - Country:US
Practice Address - Phone:630-812-8816
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-08-12
Last Update Date:2024-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL150.113815101YM0800X, 1041C0700X
IL150113815104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical