Healthcare Provider Details

I. General information

NPI: 1104674621
Provider Name (Legal Business Name): MODERN PSYCH AND WELLNESS PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/09/2024
Last Update Date: 03/18/2025
Certification Date: 03/18/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

21415 GODDARD RD
TAYLOR MI
48180-4247
US

IV. Provider business mailing address

21415 GODDARD RD
TAYLOR MI
48180-4247
US

V. Phone/Fax

Practice location:
  • Phone: 313-737-0023
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code103TA0400X
TaxonomyAddiction (Substance Use Disorder) Psychologist
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number
License Number State

VIII. Authorized Official

Name: RANA SUCCURRO
Title or Position: OWNER
Credential: MD
Phone: 248-667-8014