Provider Demographics
NPI:1538252549
Name:MCCOMAS, JR., DOUGLAS L (LMSW)
Entity type:Individual
Prefix:MR
First Name:DOUGLAS
Middle Name:L
Last Name:MCCOMAS, JR.
Suffix:
Gender:M
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:950 W MONROE ST
Mailing Address - Street 2:SUITE 500
Mailing Address - City:JACKSON
Mailing Address - State:MI
Mailing Address - Zip Code:49202-2079
Mailing Address - Country:US
Mailing Address - Phone:517-788-8330
Mailing Address - Fax:
Practice Address - Street 1:950 W MONROE ST
Practice Address - Street 2:SUITE 500
Practice Address - City:JACKSON
Practice Address - State:MI
Practice Address - Zip Code:49202-2079
Practice Address - Country:US
Practice Address - Phone:517-788-8330
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6301006289103T00000X
MI63010062691041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered103T00000XBehavioral Health & Social Service ProvidersPsychologist
Not Answered1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI08972830OtherBLUE CROSS AND BLUE SHIEL
MI5150461OtherAETNA
MION92920Medicare ID - Type Unspecified