Provider Demographics
NPI:1558810531
Name:BAILEY, MILDRED
Entity Type:Individual
Prefix:
First Name:MILDRED
Middle Name:
Last Name:BAILEY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:101 MIA AVE
Mailing Address - Street 2:
Mailing Address - City:DAYTON
Mailing Address - State:OH
Mailing Address - Zip Code:45417-9011
Mailing Address - Country:US
Mailing Address - Phone:937-559-5161
Mailing Address - Fax:
Practice Address - Street 1:101 MIA AVE
Practice Address - Street 2:
Practice Address - City:DAYTON
Practice Address - State:OH
Practice Address - Zip Code:45417-9011
Practice Address - Country:US
Practice Address - Phone:937-559-5161
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-10-01
Last Update Date:2016-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH111068101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)