Provider Demographics
NPI:1841348356
Name:DOUGLAS, CORI CARTER (MSW, LCSW)
Entity type:Individual
Prefix:
First Name:CORI
Middle Name:CARTER
Last Name:DOUGLAS
Suffix:
Gender:F
Credentials:MSW, LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2720 FREDERICA ST
Mailing Address - Street 2:
Mailing Address - City:OWENSBORO
Mailing Address - State:KY
Mailing Address - Zip Code:42301-5442
Mailing Address - Country:US
Mailing Address - Phone:270-926-2484
Mailing Address - Fax:270-685-6015
Practice Address - Street 1:2720 FREDERICA ST
Practice Address - Street 2:
Practice Address - City:OWENSBORO
Practice Address - State:KY
Practice Address - Zip Code:42301-5442
Practice Address - Country:US
Practice Address - Phone:270-926-2484
Practice Address - Fax:270-685-6015
Is Sole Proprietor?:No
Enumeration Date:2007-01-08
Last Update Date:2015-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY34231041C0700X
KY5102104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY8557Medicare ID - Type UnspecifiedMEDICARE
KY30615058Medicaid