Provider Demographics
NPI:1790334407
Name:MODERN LIFE COUNSELING LLC
Entity Type:Organization
Organization Name:MODERN LIFE COUNSELING LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:LISA
Authorized Official - Middle Name:
Authorized Official - Last Name:SULLIVAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:813-376-9700
Mailing Address - Street 1:13902 N DALE MABRY HWY
Mailing Address - Street 2:SUITE 230
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33618-2428
Mailing Address - Country:US
Mailing Address - Phone:813-376-9700
Mailing Address - Fax:813-936-3585
Practice Address - Street 1:13902 N DALE MABRY HWY
Practice Address - Street 2:SUITE 240
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33618-2428
Practice Address - Country:US
Practice Address - Phone:813-376-9700
Practice Address - Fax:813-936-3585
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-09-05
Last Update Date:2019-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family TherapistGroup - Single Specialty