NPIMap

Organization Active NPI

Modern Mojo

  • Mental Health Clinic/Center (Including Community Mental Health Center)
  • Grand Rapids, MN
National Provider Identifier
1902344591
Registry record updated Mar 8, 2023
On this page

Key facts

NPPES NPI Registry
Primary specialty
Mental Health Clinic/Center (Including Community Mental Health Center)Taxonomy code 261QM0801X
Legal business name
MODERN MOJO
Practice address
28 NW 4TH St
Suite a
Grand Rapids, MN 55744-2714
Phone
(218) 999-7750
NPI assigned
Feb 3, 2017
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Mar 8, 2023

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

Authorized official

Name
Tonya Marie Zimmerman
Title
Office Manager
Phone
(218) 999-7750

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Mental Health Clinic/Center (Including Community Mental Health Center) 261QM0801X Primary

Addresses

Primary practice location

28 NW 4TH St
Suite a
Grand Rapids, MN 55744-2714

Mailing address

28 NW 4TH St
Suite a
Grand Rapids, MN 55744-2714
Phone (218) 999-7750

Other practice location 1

1708 1st St S
Willmar, MN 56201-4228
Phone (218) 999-7750

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in MN

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
O20170725000993 MN Part B Supplier - Clinic/Group Practice 1456621457 Receives reassigned benefits from 6 practitioners
Practice locations: Grand Rapids, MN; Willmar, MN

Laboratory certificates & supplier records

Derived by NPIMap

These CMS records do not include an NPI. They are shown because their name and street address match this provider’s.

CLIA laboratory certificates

CLIA numberLaboratoryCertificateExpires
24D2134350Modern Mojo28 NW 4TH Street Suite a, Grand Rapids, MN 55744Certificate of waiverJul 31, 2027

National Provider Directory

National Provider Directory

Locations

28 NW 4th St
Ste A
Grand Rapids, MN 55744
Phone (218) 326-1274

1708 1st St S
Willmar, MN 56201
Phone (218) 999-7750

Practitioners & affiliated clinicians

Practitioners 9

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles.

NPI Registry JSON

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

{
    "created_epoch": "1486080000000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1678233600000",
    "number": "1902344591",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "28 NW 4TH ST",
            "address_2": "SUITE A",
            "city": "GRAND RAPIDS",
            "state": "MN",
            "postal_code": "557442714",
            "telephone_number": "218-999-7750"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "28 NW 4TH ST",
            "address_2": "SUITE A",
            "city": "GRAND RAPIDS",
            "state": "MN",
            "postal_code": "557442714",
            "telephone_number": "218-999-7750"
        }
    ],
    "practiceLocations": [
        {
            "address_1": "1708 1st St S",
            "address_purpose": "LOCATION",
            "city": "Willmar",
            "state": "MN",
            "postal_code": "562014228",
            "country_code": "US",
            "telephone_number": "218-999-7750",
            "fax_number": "218-999-9461",
            "country_name": "United States",
            "address_type": "DOM"
        }
    ],
    "basic": {
        "organization_name": "MODERN MOJO",
        "organizational_subpart": "NO",
        "enumeration_date": "2017-02-03",
        "last_updated": "2023-03-08",
        "certification_date": "2023-03-08",
        "status": "A",
        "authorized_official_last_name": "ZIMMERMAN",
        "authorized_official_first_name": "TONYA",
        "authorized_official_middle_name": "MARIE",
        "authorized_official_title_or_position": "OFFICE MANAGER",
        "authorized_official_telephone_number": "218-999-7750"
    },
    "taxonomies": [
        {
            "code": "261QM0801X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Mental Health (Including Community Mental Health Center)",
            "state": null,
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

Other providers in Grand Rapids, MN

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Mar 8, 2023; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
  • Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments.
  • Medicare Care Compare (CMS): clinician profile, group practices, facility affiliations, MIPS scores and star ratings.
  • National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.