Provider Demographics
NPI:1013516145
Name:MODERN SOUL THERAPY LLC
Entity Type:Organization
Organization Name:MODERN SOUL THERAPY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:THERAPIST
Authorized Official - Prefix:
Authorized Official - First Name:MALLORY
Authorized Official - Middle Name:A
Authorized Official - Last Name:INGRAM
Authorized Official - Suffix:
Authorized Official - Credentials:LCPC
Authorized Official - Phone:740-408-6407
Mailing Address - Street 1:375 MARKET ST UNIT 304
Mailing Address - Street 2:
Mailing Address - City:BRIGHTON
Mailing Address - State:MA
Mailing Address - Zip Code:02135-2754
Mailing Address - Country:US
Mailing Address - Phone:740-408-6407
Mailing Address - Fax:
Practice Address - Street 1:2000 N RACINE AVE STE 2160
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60614-4045
Practice Address - Country:US
Practice Address - Phone:740-408-6407
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-10-20
Last Update Date:2020-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
09322531OtherPRIVATE INSURANCE