Provider Demographics
NPI:1053408377
Name:MENDELIS MENTAL HEALTH CENTER LLC
Entity type:Organization
Organization Name:MENDELIS MENTAL HEALTH CENTER LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:PETER
Authorized Official - Middle Name:S
Authorized Official - Last Name:MENDELIS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:301-638-5001
Mailing Address - Street 1:11315 PEMBROOKE SQ STE 112
Mailing Address - Street 2:
Mailing Address - City:WALDORF
Mailing Address - State:MD
Mailing Address - Zip Code:20603-4806
Mailing Address - Country:US
Mailing Address - Phone:301-638-5001
Mailing Address - Fax:301-638-5003
Practice Address - Street 1:11315 PEMBROOKE SQ STE 112
Practice Address - Street 2:
Practice Address - City:WALDORF
Practice Address - State:MD
Practice Address - Zip Code:20603-4806
Practice Address - Country:US
Practice Address - Phone:301-638-5001
Practice Address - Fax:301-638-5003
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-06
Last Update Date:2011-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD129091041C0700X
MDD00255862084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Single Specialty
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD546610500Medicaid
MD950006501Medicaid
MD950006501Medicaid