Basic Information
| Provider Information | |||||||||
| NPI: | 1902344591 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | MODERN MOJO | ||||||||
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| Mailing Information | |||||||||
| Address1: | 28 NW 4TH ST | ||||||||
| Address2: | SUITE A | ||||||||
| City: | GRAND RAPIDS | ||||||||
| State: | MN | ||||||||
| PostalCode: | 557442714 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2189997750 | ||||||||
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| Practice Location | |||||||||
| Address1: | 28 NW 4TH ST | ||||||||
| Address2: | SUITE A | ||||||||
| City: | GRAND RAPIDS | ||||||||
| State: | MN | ||||||||
| PostalCode: | 557442714 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2189997750 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/03/2017 | ||||||||
| LastUpdateDate: | 02/03/2017 | ||||||||
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| AuthorizedOfficialLastName: | ZIMMERMAN-DESCHEPPER | ||||||||
| AuthorizedOfficialFirstName: | TRACY | ||||||||
| AuthorizedOfficialMiddleName: | A | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 2189997750 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | PMHNP | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QM0801X | Y | Ambulatory Health Care Facilities | Clinic/Center | Mental Health (Including Community Mental Health Center) |
No ID Information.