Provider Demographics
NPI:1366883688
Name:DOUGLASS, CYNTHIA S (MA, LPC)
Entity type:Individual
Prefix:
First Name:CYNTHIA
Middle Name:S
Last Name:DOUGLASS
Suffix:
Gender:F
Credentials:MA, LPC
Other - Prefix:
Other - First Name:POLLY
Other - Middle Name:S
Other - Last Name:DOUGLASS
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MA, LPC
Mailing Address - Street 1:5688 COLLEGE PL
Mailing Address - Street 2:
Mailing Address - City:BOULDER
Mailing Address - State:CO
Mailing Address - Zip Code:80303-2951
Mailing Address - Country:US
Mailing Address - Phone:303-618-1636
Mailing Address - Fax:
Practice Address - Street 1:1919 7TH ST
Practice Address - Street 2:
Practice Address - City:BOULDER
Practice Address - State:CO
Practice Address - Zip Code:80302-5025
Practice Address - Country:US
Practice Address - Phone:720-316-7616
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-07-15
Last Update Date:2016-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO12573101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional