Healthcare Provider Details

I. General information

NPI: 1881970531
Provider Name (Legal Business Name): MARKUS T DOUGLAS LSW
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/26/2011
Last Update Date: 10/26/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

136 WESTCHESTER DR
AUSTINTOWN OH
44515-3965
US

IV. Provider business mailing address

136 WESTCHESTER DR
AUSTINTOWN OH
44515-3965
US

V. Phone/Fax

Practice location:
  • Phone: 330-270-1400
  • Fax: 330-270-1404
Mailing address:
  • Phone: 330-270-1400
  • Fax: 330-270-1404

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License NumberS.0026089
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: