Provider Demographics
NPI:1942060215
Name:MODERN MYSTICS, LLC
Entity Type:Organization
Organization Name:MODERN MYSTICS, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:FOUNDER/CEO
Authorized Official - Prefix:
Authorized Official - First Name:SHANNON
Authorized Official - Middle Name:
Authorized Official - Last Name:FAHY
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:919-839-9721
Mailing Address - Street 1:637 BARNESWYCK DR
Mailing Address - Street 2:
Mailing Address - City:FUQUAY VARINA
Mailing Address - State:NC
Mailing Address - Zip Code:27526-2277
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:637 BARNESWYCK DR
Practice Address - Street 2:
Practice Address - City:FUQUAY VARINA
Practice Address - State:NC
Practice Address - Zip Code:27526-2277
Practice Address - Country:US
Practice Address - Phone:919-839-9721
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-03-21
Last Update Date:2024-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Multi-Specialty
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty
No175F00000XOther Service ProvidersNaturopathGroup - Multi-Specialty
No175T00000XOther Service ProvidersPeer SpecialistGroup - Multi-Specialty