Provider Demographics
NPI:1194130955
Name:MACDOUGALL, KATHLEEN (LICSW)
Entity type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:
Last Name:MACDOUGALL
Suffix:
Gender:F
Credentials:LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:111 BEDFORD DR NE
Mailing Address - Street 2:
Mailing Address - City:PORT CHARLOTTE
Mailing Address - State:FL
Mailing Address - Zip Code:33952-8106
Mailing Address - Country:US
Mailing Address - Phone:978-821-8160
Mailing Address - Fax:
Practice Address - Street 1:111 BEDFORD DR NE
Practice Address - Street 2:
Practice Address - City:PORT CHARLOTTE
Practice Address - State:FL
Practice Address - Zip Code:33952-8106
Practice Address - Country:US
Practice Address - Phone:978-821-8160
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-06-30
Last Update Date:2025-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MALICSW123081104100000X
FL119488104100000X
MA1164411041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker