Provider Demographics
NPI:1699149294
Name:DOUGLAS, RAMONA DENISE (MSW)
Entity type:Individual
Prefix:
First Name:RAMONA
Middle Name:DENISE
Last Name:DOUGLAS
Suffix:
Gender:F
Credentials:MSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12237 WASHBURN ST
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48204-5422
Mailing Address - Country:US
Mailing Address - Phone:313-926-7463
Mailing Address - Fax:
Practice Address - Street 1:12237 WASHBURN ST
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48204-5422
Practice Address - Country:US
Practice Address - Phone:313-926-7463
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-11-19
Last Update Date:2019-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YA0400X, 101YM0800X, 101YS0200X, 103K00000X, 103TC1900X
MI6801102962104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YS0200XBehavioral Health & Social Service ProvidersCounselorSchool
No103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounseling
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI802359320Medicaid