MEDICARE: MRS. DORN M DOUGAN LICSW

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1041C0700X	Clinical Social Worker	ISW02408	RI

General Provider Information

NPI Number	:	1215353230
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. DORN M DOUGAN LICSW

Provider Business Mailing Address
First Line	:	101 FRIENDSHIP ST
Second Line	:
City	:	PROVIDENCE
State	:	RI
Zip	:	02903-3716
Country	:	US
Telephone Number	:	401-528-3820
Fax Number	:

Provider Business Practice Location Address
First Line	:	101 FRIENDSHIP ST
Second Line	:
City	:	PROVIDENCE
State	:	RI
Zip	:	02903-3716
Country	:	US
Telephone Number	:	401-528-3820
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/14/2014
Last Update Date	:	03/14/2014

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