Basic Information
| Provider Information | |||||||||
| NPI: | 1235780016 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DOUGLAS | ||||||||
| FirstName: | EMERSON | ||||||||
| MiddleName: | LEE | ||||||||
| NamePrefix: | MR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | LISW | ||||||||
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| Mailing Information | |||||||||
| Address1: | 9220 MENTOR AVE | ||||||||
| Address2: | |||||||||
| City: | MENTOR | ||||||||
| State: | OH | ||||||||
| PostalCode: | 440606412 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4403549924 | ||||||||
| FaxNumber: | 8332098465 | ||||||||
| Practice Location | |||||||||
| Address1: | 30800 CHAGRIN BLVD | ||||||||
| Address2: | |||||||||
| City: | PEPPER PIKE | ||||||||
| State: | OH | ||||||||
| PostalCode: | 441245925 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2165910324 | ||||||||
| FaxNumber: | 2165911243 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/24/2019 | ||||||||
| LastUpdateDate: | 05/05/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 05/05/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | I.2002146 | OH | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
ID Information
| ID | Type | State | Issuer | Description | 2864093 | 05 | OH | MEDICAID |