Provider Demographics
NPI:1114502929
Name:MODERN MIND THERAPEUTIC SERVICES LLC
Entity Type:Organization
Organization Name:MODERN MIND THERAPEUTIC SERVICES LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:THERAPIST/ OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JESSICA
Authorized Official - Middle Name:
Authorized Official - Last Name:AYALA
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:973-930-9749
Mailing Address - Street 1:1114 MAIN AVE UNIT 6035
Mailing Address - Street 2:
Mailing Address - City:CLIFTON
Mailing Address - State:NJ
Mailing Address - Zip Code:07015-7200
Mailing Address - Country:US
Mailing Address - Phone:973-910-0900
Mailing Address - Fax:
Practice Address - Street 1:49 KULICK ST
Practice Address - Street 2:
Practice Address - City:CLIFTON
Practice Address - State:NJ
Practice Address - Zip Code:07011-2375
Practice Address - Country:US
Practice Address - Phone:973-930-9749
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-03-12
Last Update Date:2021-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
No251S00000XAgenciesCommunity/Behavioral Health
No261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health
No261QM0855XAmbulatory Health Care FacilitiesClinic/CenterAdolescent and Children Mental Health