Provider Demographics
NPI:1346431335
Name:MDC2 LLC
Entity Type:Organization
Organization Name:MDC2 LLC
Other - Org Name:RESTORATION HOUSE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CLINICAL PARTNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:MARYDORA
Authorized Official - Middle Name:
Authorized Official - Last Name:CONLEY
Authorized Official - Suffix:
Authorized Official - Credentials:LMFT/LCSW
Authorized Official - Phone:502-618-1201
Mailing Address - Street 1:9319 TAYLORSVILLE RD
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40299-1737
Mailing Address - Country:US
Mailing Address - Phone:502-618-1201
Mailing Address - Fax:502-618-2609
Practice Address - Street 1:9319 TAYLORSVILLE RD
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40299-1737
Practice Address - Country:US
Practice Address - Phone:502-618-1201
Practice Address - Fax:502-618-2609
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-08-06
Last Update Date:2009-12-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY19661041C0700X
KY0575106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty
No106H00000XBehavioral Health & Social Service ProvidersMarriage & Family TherapistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY1649473133OtherINDIVIDUAL NPI
KY1649473133OtherINDIVIDUAL NPI