=====================================================
General NPI Number Information
=====================================================
NPI Number | 1083169478
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MODERN THERAPY & COUNSELING, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/16/2016
-----------------------------------------------------
Last Update Date | 08/16/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 88 RIBERIA ST SUITE 150
-----------------------------------------------------
City | SAINT AUGUSTINE
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32084-3300
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 904-392-1505
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4071 NEW HAMPSHIRE RD
-----------------------------------------------------
City | ELKTON
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32033-2124
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 904-392-1505
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | LICENSED MENTAL HEALTH COUNSELOR
-----------------------------------------------------
Name | MRS. JANUARY L TURNER
-----------------------------------------------------
Credential | MA, LMHC
-----------------------------------------------------
Telephone | 904-392-1505
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YM0800X
-----------------------------------------------------
Taxonomy Name | Mental Health Counselor
-----------------------------------------------------
License Number | MH14185
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------