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General NPI Number Information
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NPI Number | 1477099141
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Entity Type | Organization
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Legal Business Name | MODERN BRAIN, LLC
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Dates
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Enumeration Date | 01/18/2017
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Last Update Date | 01/18/2017
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Provider Practice Location Address
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Address Line | 363 7TH AVE 11TH FLOOR, SUITE 5
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City | NEW YORK
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State | NY
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Zip | 10001-3904
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Country | US
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Telephone | 646-706-2372
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Fax |
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Provider Business Mailing Address
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Address Line | 245 E 54TH ST 8B
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City | NEW YORK
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State | NY
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Zip | 10022-4707
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Country | US
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Telephone | 646-706-2372
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Fax |
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Authorized Official
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Title or Position | PRESIDENT
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Name | DR. STELLA KARANTZOULIS
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Credential | PH.D.
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Telephone | 646-706-2372
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 103G00000X
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Taxonomy Name | Clinical Neuropsychologist
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License Number | 017975
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License Number State | NY
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