Healthcare Provider Details

I. General information

NPI: 1497840672
Provider Name (Legal Business Name): PATRICIA A DOUGLAS L.C.S.W
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/04/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

931 W PARK AVE
OCEAN NJ
07712-7207
US

IV. Provider business mailing address

66 OAKWOOD DR
MEDFORD NJ
08055-8824
US

V. Phone/Fax

Practice location:
  • Phone: 732-493-8080
  • Fax: 732-493-8810
Mailing address:
  • Phone: 732-493-8080
  • Fax: 732-493-8810

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number44SC00592200
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: