MEDICARE: MODERN PATH. LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YM0800X	Mental Health Counselor	MH7359	FL
2	101Y00000X	Counselor	LPC004808	GA

General Provider Information

NPI Number	:	1023533106
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MODERN PATH. LLC

Provider Business Mailing Address
First Line	:	3720 CHAMBLEE DUNWOODY RD STE D2
Second Line	:
City	:	ATLANTA
State	:	GA
Zip	:	30341-2064
Country	:	US
Telephone Number	:	678-802-9355
Fax Number	:

Provider Business Practice Location Address
First Line	:	3720 CHAMBLEE DUNWOODY RD STE D2
Second Line	:
City	:	ATLANTA
State	:	GA
Zip	:	30341-2064
Country	:	US
Telephone Number	:	678-802-9355
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	NICOLE M FUENTES
Credential	:	LPC, LMHC
Telephone Number	:	678-802-9355

Provider Enumeration Date	:	08/09/2017
Last Update Date	:	06/18/2019

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