Provider Demographics
NPI:1902955206
Name:DOUGLASS, ROSE M (LCSW)
Entity Type:Individual
Prefix:
First Name:ROSE
Middle Name:M
Last Name:DOUGLASS
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:104 S FRONT AVE
Mailing Address - Street 2:
Mailing Address - City:PRESTONSBURG
Mailing Address - State:KY
Mailing Address - Zip Code:41653-1614
Mailing Address - Country:US
Mailing Address - Phone:606-886-8572
Mailing Address - Fax:606-886-4433
Practice Address - Street 1:104 S FRONT AVE
Practice Address - Street 2:
Practice Address - City:PRESTONSBURG
Practice Address - State:KY
Practice Address - Zip Code:41653-1614
Practice Address - Country:US
Practice Address - Phone:606-886-8572
Practice Address - Fax:606-886-4433
Is Sole Proprietor?:No
Enumeration Date:2007-01-09
Last Update Date:2020-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY7951041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY30615058Medicaid
KY0575124Medicare ID - Type UnspecifiedMEDICARE
KY30615058Medicaid