Provider Demographics
NPI:1417636309
Name:MODERN RECOVERY, LLC
Entity Type:Organization
Organization Name:MODERN RECOVERY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:LAURA
Authorized Official - Middle Name:
Authorized Official - Last Name:NUSS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:203-200-8556
Mailing Address - Street 1:11445 E VIA LINDA
Mailing Address - Street 2:STE 2-617
Mailing Address - City:SCOTTSDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85259
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:702 HOUSTON ST # 118
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76102-5004
Practice Address - Country:US
Practice Address - Phone:203-200-8556
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-07-17
Last Update Date:2023-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)