1437549755 NPI number — MODERN PSYCHOLOGIST NETWORK LLC

Table of content: (NPI 1437549755)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1437549755 NPI number — MODERN PSYCHOLOGIST NETWORK LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MODERN PSYCHOLOGIST NETWORK LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
6
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1437549755
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/10/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
463 WESTFIELD BLVD APT 121
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
TEMPLE
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
76502-5319
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
16 E AVENUE A STE 212
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
TEMPLE
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
76501
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
305-249-1694
Provider Business Practice Location Address Fax Number:
305-647-6045
Provider Enumeration Date:
01/24/2015

Additional Information

Authorized Official

Authorized Official Last Name:
CRESPO
Authorized Official First Name:
BARON
Authorized Official Middle Name:
Authorized Official Title or Position:
CLINICAL & FORENSIC PSYCHOLOGIST
Authorized Official Telephone Number:
305-249-1694

Provider Taxonomy Codes

  • Taxonomy code: 103T00000X , with the licence number:  37853 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 381189501 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".
  • Identifier: 631971 . This is a "MEDICARE" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".




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