Provider Demographics
NPI:1720873433
Name:DOUGLASS, MICHELE VICTORIA (LCSWA, LCASA)
Entity type:Individual
Prefix:
First Name:MICHELE
Middle Name:VICTORIA
Last Name:DOUGLASS
Suffix:
Gender:
Credentials:LCSWA, LCASA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2704 EVERS DR
Mailing Address - Street 2:
Mailing Address - City:RALEIGH
Mailing Address - State:NC
Mailing Address - Zip Code:27610-4924
Mailing Address - Country:US
Mailing Address - Phone:919-559-8490
Mailing Address - Fax:
Practice Address - Street 1:1740 HERITAGE CENTER DR STE 201
Practice Address - Street 2:
Practice Address - City:WAKE FOREST
Practice Address - State:NC
Practice Address - Zip Code:27587-9849
Practice Address - Country:US
Practice Address - Phone:919-556-6501
Practice Address - Fax:919-556-4933
Is Sole Proprietor?:No
Enumeration Date:2025-04-12
Last Update Date:2025-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCLCAS-30416101YA0400X
NCPO216531041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)