Provider Demographics
NPI:1699251553
Name:MODERN PSYCHIATRY & WELLNESS, LLC
Entity type:Organization
Organization Name:MODERN PSYCHIATRY & WELLNESS, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:C.O.O.
Authorized Official - Prefix:MS
Authorized Official - First Name:SUSANNA
Authorized Official - Middle Name:MARIE
Authorized Official - Last Name:LOZANO
Authorized Official - Suffix:
Authorized Official - Credentials:LISW-S, LICDC-CS
Authorized Official - Phone:513-299-4025
Mailing Address - Street 1:1910 FAIRGROVE AVE STE E
Mailing Address - Street 2:
Mailing Address - City:HAMILTON
Mailing Address - State:OH
Mailing Address - Zip Code:45011-1930
Mailing Address - Country:US
Mailing Address - Phone:513-795-7557
Mailing Address - Fax:513-795-7518
Practice Address - Street 1:1910 FAIRGROVE AVE STE E
Practice Address - Street 2:
Practice Address - City:HAMILTON
Practice Address - State:OH
Practice Address - Zip Code:45011-1930
Practice Address - Country:US
Practice Address - Phone:513-795-7557
Practice Address - Fax:513-795-7518
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-07-13
Last Update Date:2020-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health
No261QH0100XAmbulatory Health Care FacilitiesClinic/CenterHealth Service
No261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
No324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0118852Medicaid