Provider Demographics
NPI:1972372746
Name:MODERN MIND WELLNESS
Entity type:Organization
Organization Name:MODERN MIND WELLNESS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER/LICENSED THERAPIST
Authorized Official - Prefix:
Authorized Official - First Name:TREVOR
Authorized Official - Middle Name:D
Authorized Official - Last Name:FRYBARGER
Authorized Official - Suffix:
Authorized Official - Credentials:LICSW
Authorized Official - Phone:507-218-8394
Mailing Address - Street 1:PO BOX 94
Mailing Address - Street 2:
Mailing Address - City:FAIRBURN
Mailing Address - State:SD
Mailing Address - Zip Code:57738-0094
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:25691 S. FAIRBURN RD
Practice Address - Street 2:
Practice Address - City:FAIRBURN
Practice Address - State:SD
Practice Address - Zip Code:57738
Practice Address - Country:US
Practice Address - Phone:507-218-8394
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-12-21
Last Update Date:2024-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Single Specialty