1285649111 NPI number — MRS. KATHLEEN DOUGLAS MSW

Table of content: MRS. KATHLEEN DOUGLAS MSW (NPI 1285649111)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1285649111 NPI number — MRS. KATHLEEN DOUGLAS MSW

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
DOUGLAS
Provider First Name:
KATHLEEN
Provider Middle Name:
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
MSW
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
DOUGLAS
Provider Other First Name:
KATHLEEN
Provider Other Middle Name:
Provider Other Name Prefix Text:
MS.
Provider Other Name Suffix Text:
Provider Other Credential Text:
LCSW
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1285649111
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/09/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
323 MT PARNASSUS RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
EAST HADDAM
Provider Business Mailing Address State Name:
CT
Provider Business Mailing Address Postal Code:
06423
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
860-873-3439
Provider Business Mailing Address Fax Number:
860-873-3439

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
FLEET & FAMILY SUPPORT CENTER
Provider Second Line Business Practice Location Address:
BOX 93 NAVSUBASENLON
Provider Business Practice Location Address City Name:
GROTON
Provider Business Practice Location Address State Name:
CT
Provider Business Practice Location Address Postal Code:
06349-5093
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
860-694-4961
Provider Business Practice Location Address Fax Number:
860-694-4018
Provider Enumeration Date:
07/29/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 1041C0700X , with the licence number:  006591 , registered in the state of CT ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 006591 . This is a "LCSW" identifier , issued by the state of ( CT ) . This identifiers is of the category "OTHER".




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