Provider Demographics
NPI:1083081335
Name:DESTILEE LLC
Entity Type:Organization
Organization Name:DESTILEE LLC
Other - Org Name:DESTILEE HEALTH CARE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:VANESSA
Authorized Official - Middle Name:
Authorized Official - Last Name:CHAPPELL LEE
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:443-244-7615
Mailing Address - Street 1:6104 WHITTEMORE CT
Mailing Address - Street 2:
Mailing Address - City:UPPER MARLBORO
Mailing Address - State:MD
Mailing Address - Zip Code:20772-4155
Mailing Address - Country:US
Mailing Address - Phone:443-244-7615
Mailing Address - Fax:
Practice Address - Street 1:6104 WHITTEMORE CT
Practice Address - Street 2:
Practice Address - City:UPPER MARLBORO
Practice Address - State:MD
Practice Address - Zip Code:20772-4155
Practice Address - Country:US
Practice Address - Phone:443-244-7615
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-08-21
Last Update Date:2015-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD6434951041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD12530000Medicaid