Provider Demographics
NPI:1225260888
Name:MODERN PSYCHIATRY AND WELLNESS LLC
Entity Type:Organization
Organization Name:MODERN PSYCHIATRY AND WELLNESS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:QUINTON
Authorized Official - Middle Name:
Authorized Official - Last Name:MOSS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:513-868-0055
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:513-297-7577
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:513-297-7577
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-08-17
Last Update Date:2020-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH261QM0850X, 261QM0850X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2444144Medicaid
OHH94767Medicare UPIN