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General NPI Number Information
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NPI Number | 1043917909
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Entity Type | Organization
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Legal Business Name | MODERN THERAPY
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Dates
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Enumeration Date | 02/10/2023
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Last Update Date | 02/10/2023
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Provider Practice Location Address
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Address Line | 1210 FOUNTAIN COVE LN
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City | LAWRENCEVILLE
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State | GA
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Zip | 30043-3974
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Country | US
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Telephone | 513-449-0445
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Fax | 513-672-9859
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Provider Business Mailing Address
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Address Line | 1210 FOUNTAIN COVE LN
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City | LAWRENCEVILLE
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State | GA
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Zip | 30043-3974
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Country | US
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Telephone | 513-449-0445
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Fax | 513-672-9859
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Authorized Official
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Title or Position | OWNER
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Name | ROBYN J KELLY
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Credential | MSW,LISW
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Telephone | 513-449-0445
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 251S00000X
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Taxonomy Name | Community/Behavioral Health Agency
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License Number |
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License Number State |
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