Provider Demographics
NPI:1285141630
Name:MDB PROFESSIONAL SERVICES LLC
Entity type:Organization
Organization Name:MDB PROFESSIONAL SERVICES LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER/CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:MARY
Authorized Official - Middle Name:E
Authorized Official - Last Name:DOUGLAS-BAILEY
Authorized Official - Suffix:
Authorized Official - Credentials:EDD CADC LCDP
Authorized Official - Phone:215-301-0053
Mailing Address - Street 1:500 HOMESTEAD ROAD
Mailing Address - Street 2:I-11
Mailing Address - City:WILMINGTON
Mailing Address - State:DE
Mailing Address - Zip Code:19805-6605
Mailing Address - Country:US
Mailing Address - Phone:215-301-0053
Mailing Address - Fax:
Practice Address - Street 1:408 E 8TH ST
Practice Address - Street 2:
Practice Address - City:WILMINGTON
Practice Address - State:DE
Practice Address - Zip Code:19801-3608
Practice Address - Country:US
Practice Address - Phone:215-301-0053
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-01-08
Last Update Date:2018-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DECD-0000095101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Single Specialty