Provider Demographics
NPI:1043917909
Name:MODERN THERAPY
Entity type:Organization
Organization Name:MODERN THERAPY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ROBYN
Authorized Official - Middle Name:J
Authorized Official - Last Name:KELLY
Authorized Official - Suffix:
Authorized Official - Credentials:MSW,LISW
Authorized Official - Phone:513-449-0445
Mailing Address - Street 1:1210 FOUNTAIN COVE LN
Mailing Address - Street 2:
Mailing Address - City:LAWRENCEVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30043-3974
Mailing Address - Country:US
Mailing Address - Phone:513-449-0445
Mailing Address - Fax:513-672-9859
Practice Address - Street 1:1210 FOUNTAIN COVE LN
Practice Address - Street 2:
Practice Address - City:LAWRENCEVILLE
Practice Address - State:GA
Practice Address - Zip Code:30043-3974
Practice Address - Country:US
Practice Address - Phone:513-449-0445
Practice Address - Fax:513-672-9859
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-02-10
Last Update Date:2023-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH1225280142Medicaid