MEDICARE: MS. LATRICE DOUGLAS MSW, LSW,CCM

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	104100000X	Social Worker	S.0901020	OH

General Provider Information

NPI Number	:	1922760628
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. LATRICE DOUGLAS MSW, LSW,CCM

Provider Business Mailing Address
First Line	:	170 CRESCENT AVE
Second Line	:
City	:	CINCINNATI
State	:	OH
Zip	:	45215-4403
Country	:	US
Telephone Number	:	513-709-9970
Fax Number	:

Provider Business Practice Location Address
First Line	:	6566 MONTGOMERY RD STE 210
Second Line	:
City	:	CINCINNATI
State	:	OH
Zip	:	45213-1523
Country	:	US
Telephone Number	:	513-709-9970
Fax Number	:

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

Provider Enumeration Date	:	10/10/2021
Last Update Date	:	10/10/2021

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