Provider Demographics
NPI:1023533106
Name:MODERN PATH. LLC
Entity type:Organization
Organization Name:MODERN PATH. LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:NICOLE
Authorized Official - Middle Name:M
Authorized Official - Last Name:FUENTES
Authorized Official - Suffix:
Authorized Official - Credentials:LPC, LMHC
Authorized Official - Phone:678-802-9355
Mailing Address - Street 1:3720 CHAMBLEE DUNWOODY RD STE D2
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30341-2064
Mailing Address - Country:US
Mailing Address - Phone:678-802-9355
Mailing Address - Fax:
Practice Address - Street 1:3720 CHAMBLEE DUNWOODY RD STE D2
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30341-2064
Practice Address - Country:US
Practice Address - Phone:678-802-9355
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-08-09
Last Update Date:2019-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMH7359101YM0800X
GALPC004808101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselorGroup - Single Specialty
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty