Provider Demographics
NPI:1174140800
Name:MD DEVELOPMENTAL AGENCY
Entity type:Organization
Organization Name:MD DEVELOPMENTAL AGENCY
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CO-OWNER
Authorized Official - Prefix:
Authorized Official - First Name:DEBRA
Authorized Official - Middle Name:
Authorized Official - Last Name:STEWART
Authorized Official - Suffix:
Authorized Official - Credentials:THERAPIST
Authorized Official - Phone:773-407-7558
Mailing Address - Street 1:2520 SAINT ROSE PKWY STE H2-216
Mailing Address - Street 2:
Mailing Address - City:HENDERSON
Mailing Address - State:NV
Mailing Address - Zip Code:89074-7783
Mailing Address - Country:US
Mailing Address - Phone:773-407-7558
Mailing Address - Fax:702-852-0430
Practice Address - Street 1:2520 SAINT ROSE PKWY STE H2-216
Practice Address - Street 2:
Practice Address - City:HENDERSON
Practice Address - State:NV
Practice Address - Zip Code:89074-7783
Practice Address - Country:US
Practice Address - Phone:773-407-7558
Practice Address - Fax:702-852-0430
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-06-29
Last Update Date:2022-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental TherapistGroup - Multi-Specialty