Basic Information
| Provider Information | |||||||||
| NPI: | 1699251553 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | MODERN PSYCHIATRY & WELLNESS, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1910 FAIRGROVE AVE STE E | ||||||||
| Address2: | |||||||||
| City: | HAMILTON | ||||||||
| State: | OH | ||||||||
| PostalCode: | 450111930 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5137957557 | ||||||||
| FaxNumber: | 5137957518 | ||||||||
| Practice Location | |||||||||
| Address1: | 1910 FAIRGROVE AVE STE E | ||||||||
| Address2: | |||||||||
| City: | HAMILTON | ||||||||
| State: | OH | ||||||||
| PostalCode: | 450111930 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5137957557 | ||||||||
| FaxNumber: | 5137957518 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/13/2018 | ||||||||
| LastUpdateDate: | 10/27/2020 | ||||||||
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| AuthorizedOfficialLastName: | LOZANO | ||||||||
| AuthorizedOfficialFirstName: | SUSANNA | ||||||||
| AuthorizedOfficialMiddleName: | MARIE | ||||||||
| AuthorizedOfficialTitleorPosition: | C.O.O. | ||||||||
| AuthorizedOfficialTelephone: | 5132994025 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MS. | ||||||||
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| AuthorizedOfficialCredential: | LISW-S, LICDC-CS | ||||||||
| NPICertificationDate: | 10/27/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QM0801X | N | Ambulatory Health Care Facilities | Clinic/Center | Mental Health (Including Community Mental Health Center) | 261QH0100X | N | Ambulatory Health Care Facilities | Clinic/Center | Health Service | 324500000X | N | Residential Treatment Facilities | Substance Abuse Rehabilitation Facility | 261QM0850X | Y | Ambulatory Health Care Facilities | Clinic/Center | Adult Mental Health |
ID Information
| ID | Type | State | Issuer | Description | 0118852 | 05 | OH | MEDICAID |