Provider Demographics
NPI:1790311207
Name:MODERN CHANGE PLLC
Entity Type:Organization
Organization Name:MODERN CHANGE PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MONIQUE
Authorized Official - Middle Name:
Authorized Official - Last Name:PORTER
Authorized Official - Suffix:
Authorized Official - Credentials:LCMHC, LCAS
Authorized Official - Phone:919-576-0084
Mailing Address - Street 1:5720 FAYETTEVILLE RD STE 202
Mailing Address - Street 2:
Mailing Address - City:DURHAM
Mailing Address - State:NC
Mailing Address - Zip Code:27713-5333
Mailing Address - Country:US
Mailing Address - Phone:919-576-0084
Mailing Address - Fax:919-797-9922
Practice Address - Street 1:5720 FAYETTEVILLE RD STE 202
Practice Address - Street 2:
Practice Address - City:DURHAM
Practice Address - State:NC
Practice Address - Zip Code:27713-5333
Practice Address - Country:US
Practice Address - Phone:919-576-0084
Practice Address - Fax:919-797-9922
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-03-16
Last Update Date:2024-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
No101Y00000XBehavioral Health & Social Service ProvidersCounselorGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
1295187763OtherNPI