Healthcare Provider Details

I. General information

NPI: 1265474381
Provider Name (Legal Business Name): MARCIA N DOUGLAS LCSW R
Entity Type: Individual
Gender: Female
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 06/12/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

106 S PERRY ST STE 4
WATKINS GLEN NY
14891-1615
US

IV. Provider business mailing address

272 S LHOMMEDIEU ST
MONTOUR FALLS NY
14865-9786
US

V. Phone/Fax

Practice location:
  • Phone: 607-535-8282
  • Fax: 607-535-8284
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number052112
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: