Provider Demographics
NPI:1649376989
Name:DOUGLAS, ELEANORE S (LPCC)
Entity type:Individual
Prefix:MS
First Name:ELEANORE
Middle Name:S
Last Name:DOUGLAS
Suffix:
Gender:F
Credentials:LPCC
Other - Prefix:MS
Other - First Name:LEA
Other - Middle Name:S
Other - Last Name:DOUGLAS
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:LPCC
Mailing Address - Street 1:1011 FLORA DR
Mailing Address - Street 2:
Mailing Address - City:SANTA FE
Mailing Address - State:NM
Mailing Address - Zip Code:87505-5221
Mailing Address - Country:US
Mailing Address - Phone:505-310-5988
Mailing Address - Fax:
Practice Address - Street 1:1011 FLORA DR
Practice Address - Street 2:
Practice Address - City:SANTA FE
Practice Address - State:NM
Practice Address - Zip Code:87505-5221
Practice Address - Country:US
Practice Address - Phone:505-310-5988
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-15
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM0091581101Y00000X, 101YA0400X, 101YM0800X, 101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered101Y00000XBehavioral Health & Social Service ProvidersCounselor
Not Answered101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Not Answered101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Not Answered101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ58032304Medicaid