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General NPI Number Information
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NPI Number | 1013516145
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Entity Type | Organization
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Legal Business Name | MODERN SOUL THERAPY LLC
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Dates
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Enumeration Date | 10/20/2020
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Last Update Date | 02/10/2025
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Provider Practice Location Address
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Address Line | 120 WHITWELL ST UNIT D-106
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City | QUINCY
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State | MA
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Zip | 02169-1998
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Country | US
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Telephone | 740-408-6407
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Fax |
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Provider Business Mailing Address
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Address Line | 120 WHITWELL ST UNIT D-106
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City | QUINCY
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State | MA
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Zip | 02169-1998
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Country | US
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Telephone | 740-408-6407
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | MALLORY A INGRAM
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Credential | LMHC, LCPC
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Telephone | 740-408-6407
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 101YM0800X
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Taxonomy Name | Mental Health Counselor
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License Number |
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License Number State |
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