Provider Demographics
NPI:1477099141
Name:MODERN BRAIN, LLC
Entity Type:Organization
Organization Name:MODERN BRAIN, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:STELLA
Authorized Official - Middle Name:
Authorized Official - Last Name:KARANTZOULIS
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:646-706-2372
Mailing Address - Street 1:245 E 54TH ST
Mailing Address - Street 2:8B
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10022-4707
Mailing Address - Country:US
Mailing Address - Phone:646-706-2372
Mailing Address - Fax:
Practice Address - Street 1:363 7TH AVE
Practice Address - Street 2:11TH FLOOR, SUITE 5
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10001-3904
Practice Address - Country:US
Practice Address - Phone:646-706-2372
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-01-18
Last Update Date:2017-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY017975103G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103G00000XBehavioral Health & Social Service ProvidersClinical NeuropsychologistGroup - Multi-Specialty