=====================================================
General NPI Number Information
=====================================================
NPI Number | 1346002086
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MODERN HEALING COLLECTIVE PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/29/2024
-----------------------------------------------------
Last Update Date | 01/29/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2621 GALLATIN PIKE
-----------------------------------------------------
City | NASHVILLE
-----------------------------------------------------
State | TN
-----------------------------------------------------
Zip | 37216-3743
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 615-502-2115
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2438 SAYERVILLE AVE
-----------------------------------------------------
City | OLD HICKORY
-----------------------------------------------------
State | TN
-----------------------------------------------------
Zip | 37138-1052
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CEO
-----------------------------------------------------
Name | TOZIA WARE
-----------------------------------------------------
Credential | ED.S, LPC-MHSP(TEMP)
-----------------------------------------------------
Telephone | 615-502-2115
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YM0800X
-----------------------------------------------------
Taxonomy Name | Mental Health Counselor
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------