Provider Demographics
NPI:1952714321
Name:INSTITUTE OF MODERN RECOVERY
Entity Type:Organization
Organization Name:INSTITUTE OF MODERN RECOVERY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MARRIAGE FAMILY THERAPIST/ OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:CRESTON
Authorized Official - Middle Name:
Authorized Official - Last Name:DAVIS
Authorized Official - Suffix:
Authorized Official - Credentials:MA THERAPIST
Authorized Official - Phone:619-288-6866
Mailing Address - Street 1:2725 CONGRESS ST
Mailing Address - Street 2:SUITE 1D
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92110-2757
Mailing Address - Country:US
Mailing Address - Phone:619-288-6866
Mailing Address - Fax:
Practice Address - Street 1:2725 CONGRESS ST
Practice Address - Street 2:SUITE 1D
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92110-2757
Practice Address - Country:US
Practice Address - Phone:619-288-6866
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-06-03
Last Update Date:2014-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA51024106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family TherapistGroup - Single Specialty