Modern Mystic, LLC

Primary specialty

Mental Health Clinic/Center (Including Community Mental Health Center)Taxonomy code 261QM0801X

License

T-0174411 Issued in NM

Legal business name

MODERN MYSTIC, LLC

Practice address

2213 Brothers Rd
Santa Fe, NM 87505-6993

Phone

(505) 988-7616

NPI assigned

Jan 23, 2016

Organization subpart

No

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name

Ms. Roxanne Mercurio, M.A.,L.M.H.C

Title

Licensed Mental Health Counselor

Phone

(505) 231-3786

Specialties & licenses 1

Addresses

Other names 1

• Roxanne Mercurio Other name

Locations

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1453507200000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1453507200000",
    "number": "1720445679",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "9 BONITO RD",
            "city": "SANTA FE",
            "state": "NM",
            "postal_code": "875088793",
            "telephone_number": "505-231-3786",
            "fax_number": "505-988-5592"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "2213 BROTHERS RD",
            "city": "SANTA FE",
            "state": "NM",
            "postal_code": "875056993",
            "telephone_number": "505-988-7616"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "MODERN MYSTIC, LLC",
        "organizational_subpart": "NO",
        "enumeration_date": "2016-01-23",
        "last_updated": "2016-01-23",
        "status": "A",
        "authorized_official_last_name": "MERCURIO",
        "authorized_official_first_name": "ROXANNE",
        "authorized_official_title_or_position": "LICENSED MENTAL HEALTH COUNSELOR",
        "authorized_official_telephone_number": "505-231-3786",
        "authorized_official_name_prefix": "Ms.",
        "authorized_official_credential": "M.A.,L.M.H.C"
    },
    "taxonomies": [
        {
            "code": "261QM0801X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Mental Health (Including Community Mental Health Center)",
            "state": "NM",
            "license": "T-0174411",
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Roxanne Mercurio",
            "code": "5",
            "type": "Other Name"
        }
    ]
}

• William Edgefield Mitchell Jr., MD
• Arianna Mladosich
• Mobile Medicine
• Natalie Moctezuma, M.S. CFY-SLP
• Marcel Millado Modelo, PTA
• Leticia Moedano, MD
• Kevin Moeller, LMSW
• Alexandrea N Moffett, MS.CCC-SLP
• Patricia Mogan
• Carly Mohler, DOM

• Mental Health Clinic/Center (Including Community Mental Health Center) in Santa Fe, NM
• Providers in Santa Fe, NM by specialty
• Mental Health Clinic/Center (Including Community Mental Health Center) in New Mexico

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jan 23, 2016; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.