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General NPI Number Information
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NPI Number | 1205326691
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Entity Type | Organization
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Legal Business Name | MODERN CONNECTIONS THERAPY, LLC
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Dates
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Enumeration Date | 05/11/2018
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Last Update Date | 07/06/2023
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Provider Practice Location Address
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Address Line | 222 S FRANCES ST
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City | SOUTH BEND
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State | IN
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Zip | 46617-3004
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Country | US
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Telephone | 708-405-9181
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Fax |
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Provider Business Mailing Address
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Address Line | 222 S FRANCES ST
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City | SOUTH BEND
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State | IN
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Zip | 46617-3004
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Country | US
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Telephone | 708-405-9181
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Fax |
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Authorized Official
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Title or Position | LICENSED CLINICAL SOCIAL WORKER
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Name | SHAWN MARIE FLYNN
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Credential | LCSW
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Telephone | 708-405-9181
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QM0850X
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Taxonomy Name | Adult Mental Health Clinic/Center
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License Number | 149019589
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License Number State | IL
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