Provider Demographics
NPI:1437549755
Name:MODERN PSYCHOLOGIST NETWORK LLC
Entity Type:Organization
Organization Name:MODERN PSYCHOLOGIST NETWORK LLC
Other - Org Name:ADVANCED LIFE INNOVATIONS PLLC
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:CLINICAL & FORENSIC PSYCHOLOGIST
Authorized Official - Prefix:
Authorized Official - First Name:BARON
Authorized Official - Middle Name:
Authorized Official - Last Name:CRESPO
Authorized Official - Suffix:
Authorized Official - Credentials:PSYD
Authorized Official - Phone:305-249-1694
Mailing Address - Street 1:463 WESTFIELD BLVD APT 121
Mailing Address - Street 2:
Mailing Address - City:TEMPLE
Mailing Address - State:TX
Mailing Address - Zip Code:76502-5319
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:16 E AVENUE A STE 212
Practice Address - Street 2:
Practice Address - City:TEMPLE
Practice Address - State:TX
Practice Address - Zip Code:76501
Practice Address - Country:US
Practice Address - Phone:305-249-1694
Practice Address - Fax:305-647-6045
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-01-24
Last Update Date:2018-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX37853103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX381189501Medicaid
TX631971OtherMEDICARE