Provider Demographics
NPI:1104255199
Name:DOUMA, MARK PAUL (MSW, LMSW)
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:PAUL
Last Name:DOUMA
Suffix:
Gender:M
Credentials:MSW, LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:116 N ALTADENA AVE
Mailing Address - Street 2:
Mailing Address - City:ROYAL OAK
Mailing Address - State:MI
Mailing Address - Zip Code:48067-1948
Mailing Address - Country:US
Mailing Address - Phone:248-591-6275
Mailing Address - Fax:
Practice Address - Street 1:116 N ALTADENA AVE
Practice Address - Street 2:
Practice Address - City:ROYAL OAK
Practice Address - State:MI
Practice Address - Zip Code:48067-1948
Practice Address - Country:US
Practice Address - Phone:248-591-6275
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-11-11
Last Update Date:2013-11-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI68010202491041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical