Provider Demographics
NPI:1316299464
Name:MARDOT PROFESSIONAL SERVICES
Entity type:Organization
Organization Name:MARDOT PROFESSIONAL SERVICES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MRS
Authorized Official - First Name:DOROTHEA
Authorized Official - Middle Name:
Authorized Official - Last Name:GARRETT
Authorized Official - Suffix:
Authorized Official - Credentials:LPC
Authorized Official - Phone:601-594-7233
Mailing Address - Street 1:2540 FLOWOOD DR
Mailing Address - Street 2:SUITE A
Mailing Address - City:FLOWOOD
Mailing Address - State:MS
Mailing Address - Zip Code:39232-9362
Mailing Address - Country:US
Mailing Address - Phone:601-594-7233
Mailing Address - Fax:601-664-6561
Practice Address - Street 1:2540 FLOWOOD DR
Practice Address - Street 2:SUITE A
Practice Address - City:FLOWOOD
Practice Address - State:MS
Practice Address - Zip Code:39232-9362
Practice Address - Country:US
Practice Address - Phone:601-594-7233
Practice Address - Fax:601-664-6561
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-10-12
Last Update Date:2012-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS0928101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Single Specialty