Provider Demographics
NPI:1124692876
Name:MODERN WELLNESS, LLC
Entity type:Organization
Organization Name:MODERN WELLNESS, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:BRANDI
Authorized Official - Middle Name:
Authorized Official - Last Name:LONG
Authorized Official - Suffix:
Authorized Official - Credentials:LPC
Authorized Official - Phone:804-382-0811
Mailing Address - Street 1:2855 RED LANE RD
Mailing Address - Street 2:
Mailing Address - City:POWHATAN
Mailing Address - State:VA
Mailing Address - Zip Code:23139-5121
Mailing Address - Country:US
Mailing Address - Phone:804-382-0811
Mailing Address - Fax:
Practice Address - Street 1:2855 RED LANE RD
Practice Address - Street 2:
Practice Address - City:POWHATAN
Practice Address - State:VA
Practice Address - Zip Code:23139-5121
Practice Address - Country:US
Practice Address - Phone:804-382-0811
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-05-18
Last Update Date:2021-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselorGroup - Single Specialty