Provider Demographics
NPI:1669096434
Name:DOUGLASS, CALLIE (MA)
Entity type:Individual
Prefix:
First Name:CALLIE
Middle Name:
Last Name:DOUGLASS
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:768 OLD HOLLOW RD
Mailing Address - Street 2:
Mailing Address - City:NORTH FERRISBURGH
Mailing Address - State:VT
Mailing Address - Zip Code:05473-6010
Mailing Address - Country:US
Mailing Address - Phone:207-213-3140
Mailing Address - Fax:
Practice Address - Street 1:185 TILLEY DR
Practice Address - Street 2:
Practice Address - City:SOUTH BURLINGTON
Practice Address - State:VT
Practice Address - Zip Code:05403-4484
Practice Address - Country:US
Practice Address - Phone:802-828-7477
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-06-08
Last Update Date:2024-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT068.0136176101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health