Provider Demographics
NPI:1003641358
Name:MOMO LLC
Entity type:Organization
Organization Name:MOMO LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MCCLAIN
Authorized Official - Middle Name:LEEDS
Authorized Official - Last Name:OWENS
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:502-509-9436
Mailing Address - Street 1:743 E BROADWAY # 217
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40202-1711
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:162 GLENN PL
Practice Address - Street 2:
Practice Address - City:LEXINGTON
Practice Address - State:KY
Practice Address - Zip Code:40505-3519
Practice Address - Country:US
Practice Address - Phone:502-509-9436
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-09-05
Last Update Date:2024-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty