MEDICARE: MODERN PSYCHIATRY AND WELLNESS LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	261QM0850X	Adult Mental Health Clinic/Center		OH

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1225260888
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MODERN PSYCHIATRY AND WELLNESS LLC

Provider Business Mailing Address
First Line	:	1910 FAIRGROVE AVE STE E
Second Line	:
City	:	HAMILTON
State	:	OH
Zip	:	45011-1930
Country	:	US
Telephone Number	:	513-795-7557
Fax Number	:	513-297-7577

Provider Business Practice Location Address
First Line	:	1910 FAIRGROVE AVE STE E
Second Line	:
City	:	HAMILTON
State	:	OH
Zip	:	45011-1930
Country	:	US
Telephone Number	:	513-795-7557
Fax Number	:	513-297-7577

Authorized Official
Title or Position	:	CEO
Name	:	DR. QUINTON MOSS
Credential	:	MD
Telephone Number	:	513-868-0055

Provider Enumeration Date	:	08/17/2009
Last Update Date	:	10/27/2020

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