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General NPI Number Information
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NPI Number | 1811341902
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Entity Type | Organization
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Legal Business Name | MODERN PSYCHOLOGICAL & ALLIED SERVICES, PLLC
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Dates
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Enumeration Date | 04/14/2016
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Last Update Date | 07/31/2018
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Provider Practice Location Address
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Address Line | 6201 BONHOMME RD STE 178N
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City | HOUSTON
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State | TX
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Zip | 77036
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Country | US
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Telephone | 281-771-2685
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Fax |
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Provider Business Mailing Address
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Address Line | 3 SUGAR CREEK CENTER BLVD STE 100
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City | SUGAR LAND
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State | TX
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Zip | 77478-2211
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Country | US
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Telephone | 281-771-2685
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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. DEVON J SUPERVILLE
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Credential | PH.D.
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Telephone | 940-632-6844
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 103T00000X
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Taxonomy Name | Psychologist
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License Number | 33636
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License Number State | TX
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Taxonomy #2
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Taxonomy Code | 251S00000X
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Taxonomy Name | Community/Behavioral Health Agency
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License Number | 33636
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License Number State | TX
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Taxonomy #3
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Taxonomy Code | 103TC0700X
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Taxonomy Name | Clinical Psychologist
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License Number | 33636
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License Number State | TX
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