MEDICARE: MODALITY, INC.

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	101YM0800X	Mental Health Counselor	MH8940	FL

General Provider Information

NPI Number	:	1396161881
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MODALITY, INC.

Provider Business Mailing Address
First Line	:	4638 ROYAL AVE
Second Line	:
City	:	JACKSONVILLE
State	:	FL
Zip	:	32205-4952
Country	:	US
Telephone Number	:	904-647-7567
Fax Number	:	904-647-7568

Provider Business Practice Location Address
First Line	:	2528 OAK ST
Second Line	:
City	:	JACKSONVILLE
State	:	FL
Zip	:	32204-4504
Country	:	US
Telephone Number	:	904-647-7567
Fax Number	:	904-647-7568

Authorized Official
Title or Position	:	PRESIDENT/OWNER
Name	:	KIMBERLY KELLY
Credential	:	LMHC
Telephone Number	:	904-647-7567

Provider Enumeration Date	:	03/09/2014
Last Update Date	:	03/09/2014

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