=====================================================
General NPI Number Information
=====================================================
NPI Number | 1285141630
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MDB PROFESSIONAL SERVICES LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/08/2018
-----------------------------------------------------
Last Update Date | 01/08/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 408 E 8TH ST
-----------------------------------------------------
City | WILMINGTON
-----------------------------------------------------
State | DE
-----------------------------------------------------
Zip | 19801-3608
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 215-301-0053
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 500 HOMESTEAD ROAD I-11
-----------------------------------------------------
City | WILMINGTON
-----------------------------------------------------
State | DE
-----------------------------------------------------
Zip | 19805-6605
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 215-301-0053
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER/CEO
-----------------------------------------------------
Name | DR. MARY E DOUGLAS-BAILEY
-----------------------------------------------------
Credential | ED.D CADC LCDP
-----------------------------------------------------
Telephone | 215-301-0053
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YA0400X
-----------------------------------------------------
Taxonomy Name | Addiction (Substance Use Disorder) Counselor
-----------------------------------------------------
License Number | CD-0000095
-----------------------------------------------------
License Number State | DE
-----------------------------------------------------