Provider Demographics
NPI:1720445679
Name:MODERN MYSTIC, LLC
Entity Type:Organization
Organization Name:MODERN MYSTIC, LLC
Other - Org Name:ROXANNE MERCURIO
Other - Org Type:Other Name
Authorized Official - Title/Position:LICENSED MENTAL HEALTH COUNSELOR
Authorized Official - Prefix:MS
Authorized Official - First Name:ROXANNE
Authorized Official - Middle Name:
Authorized Official - Last Name:MERCURIO
Authorized Official - Suffix:
Authorized Official - Credentials:MA,LMHC
Authorized Official - Phone:505-231-3786
Mailing Address - Street 1:9 BONITO RD
Mailing Address - Street 2:
Mailing Address - City:SANTA FE
Mailing Address - State:NM
Mailing Address - Zip Code:87508-8793
Mailing Address - Country:US
Mailing Address - Phone:505-231-3786
Mailing Address - Fax:505-988-5592
Practice Address - Street 1:2213 BROTHERS RD
Practice Address - Street 2:
Practice Address - City:SANTA FE
Practice Address - State:NM
Practice Address - Zip Code:87505-6993
Practice Address - Country:US
Practice Address - Phone:505-988-7616
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-01-23
Last Update Date:2016-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMT-0174411261QM0801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)