Provider Demographics
NPI:1811341902
Name:MODERN PSYCHOLOGICAL & ALLIED SERVICES, PLLC
Entity type:Organization
Organization Name:MODERN PSYCHOLOGICAL & ALLIED SERVICES, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:DEVON
Authorized Official - Middle Name:J
Authorized Official - Last Name:SUPERVILLE
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:940-632-6844
Mailing Address - Street 1:3 SUGAR CREEK CENTER BLVD STE 100
Mailing Address - Street 2:
Mailing Address - City:SUGAR LAND
Mailing Address - State:TX
Mailing Address - Zip Code:77478-2211
Mailing Address - Country:US
Mailing Address - Phone:281-771-2685
Mailing Address - Fax:
Practice Address - Street 1:6201 BONHOMME RD STE 178N
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77036
Practice Address - Country:US
Practice Address - Phone:281-771-2685
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-04-14
Last Update Date:2018-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX33636103T00000X, 251S00000X, 103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Multi-Specialty
No103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Multi-Specialty
No251S00000XAgenciesCommunity/Behavioral HealthGroup - Multi-Specialty