Healthcare Provider Details

I. General information

NPI: 1699251553
Provider Name (Legal Business Name): MODERN PSYCHIATRY & WELLNESS, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/13/2018
Last Update Date: 10/27/2020
Certification Date: 10/27/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1910 FAIRGROVE AVE STE E
HAMILTON OH
45011-1930
US

IV. Provider business mailing address

1910 FAIRGROVE AVE STE E
HAMILTON OH
45011-1930
US

V. Phone/Fax

Practice location:
  • Phone: 513-795-7557
  • Fax: 513-795-7518
Mailing address:
  • Phone: 513-795-7557
  • Fax: 513-795-7518

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QH0100X
TaxonomyHealth Service Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code324500000X
TaxonomySubstance Abuse Rehabilitation Facility
License Number
License Number State

VIII. Authorized Official

Name: MS. SUSANNA MARIE LOZANO
Title or Position: C.O.O.
Credential: LISW-S, LICDC-CS
Phone: 513-299-4025