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General NPI Number Information
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NPI Number | 1144496365
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Entity Type | Organization
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Legal Business Name | MODERN WELLNESS PLLC
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Dates
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Enumeration Date | 05/07/2008
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Last Update Date | 05/07/2008
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Provider Practice Location Address
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Address Line | 1107F W BROAD ST
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City | ELIZABETHTOWN
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State | NC
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Zip | 28337-9483
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Country | US
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Telephone | 910-862-4009
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Fax | 910-862-6004
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Provider Business Mailing Address
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Address Line | PO BOX 2482
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City | ELIZABETHTOWN
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State | NC
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Zip | 28337-2482
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Country | US
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Telephone | 910-862-4009
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Fax | 910-862-6004
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Authorized Official
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Title or Position | OWNER
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Name | MRS. KRISTI STARR BALDWIN ROOKS
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Credential | MA, LPC
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Telephone | 910-914-0011
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 101YP2500X
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Taxonomy Name | Professional Counselor
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License Number | 3512
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License Number State | NC
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