Basic Information
| Provider Information | |||||||||
| NPI: | 1548563620 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MCDOUGALL | ||||||||
| FirstName: | CASEY | ||||||||
| MiddleName: | LEE | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | PH.D., L.P. | ||||||||
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| Mailing Information | |||||||||
| Address1: | BOX 497 | ||||||||
| Address2: | HWY 1 AVE | ||||||||
| City: | RED LAKE | ||||||||
| State: | MN | ||||||||
| PostalCode: | 56671 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2186793912 | ||||||||
| FaxNumber: | 2186790181 | ||||||||
| Practice Location | |||||||||
| Address1: | HWY 1 HOSPITAL DRIVE | ||||||||
| Address2: | BOX 497 | ||||||||
| City: | RED LAKE | ||||||||
| State: | MN | ||||||||
| PostalCode: | 56671 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2186793912 | ||||||||
| FaxNumber: | 2186790181 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/13/2010 | ||||||||
| LastUpdateDate: | 07/11/2012 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103TC0700X | LP 5341 | MN | Y | Behavioral Health & Social Service Providers | Psychologist | Clinical | 103T00000X | LP 5341 | MN | N | Behavioral Health & Social Service Providers | Psychologist | 103TC2200X | LP 5341 | MN | N | Behavioral Health & Social Service Providers | Psychologist | Clinical Child & Adolescent |
ID Information
| ID | Type | State | Issuer | Description | 1508809765 | 05 | MN | MEDICAID | LP 5341 | 01 | MN | MN BOARD OF PSYCHOLOGY LICENSE # | OTHER |