Provider Demographics
NPI:1396072674
Name:DOUGLAS, ELLIOT TAYLOR (LMHC, BCBA)
Entity type:Individual
Prefix:
First Name:ELLIOT
Middle Name:TAYLOR
Last Name:DOUGLAS
Suffix:
Gender:M
Credentials:LMHC, BCBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:139 CORNELL ST
Mailing Address - Street 2:
Mailing Address - City:KINGSTON
Mailing Address - State:NY
Mailing Address - Zip Code:12401-3633
Mailing Address - Country:US
Mailing Address - Phone:845-338-1234
Mailing Address - Fax:845-338-6284
Practice Address - Street 1:139 CORNELL ST
Practice Address - Street 2:
Practice Address - City:KINGSTON
Practice Address - State:NY
Practice Address - Zip Code:12401-3633
Practice Address - Country:US
Practice Address - Phone:845-338-1234
Practice Address - Fax:845-338-6284
Is Sole Proprietor?:No
Enumeration Date:2009-11-08
Last Update Date:2016-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY005051101YM0800X
103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst