NPIMap

Organization Active NPI

Modern Mystics, LLC

  • Clinical Social Worker
  • Fuquay Varina, NC
National Provider Identifier
1942060215
Registry record updated Mar 21, 2024
On this page

Key facts

NPPES NPI Registry
Primary specialty
Clinical Social WorkerTaxonomy code 1041C0700X
Legal business name
MODERN MYSTICS, LLC
Practice address
637 Barneswyck Dr
Fuquay Varina, NC 27526-2277
Phone
(919) 839-9721
NPI assigned
Mar 21, 2024
Last updated
Mar 21, 2024By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Mar 21, 2024

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

Authorized official

Name
Shannon Fahy, LCSWNPI 1801030168
Title
Founder/Ceo
Phone
(919) 839-9721

Authorized official NPPES reports the official by name only. The link goes to the one practitioner connected to this organization with that name.

Specialties & licenses 5

Specialty (taxonomy)CodeLicenseStatePrimary
Addiction (Substance Use Disorder) Counselor 101YA0400X
Mental Health Counselor 101YM0800X
Clinical Social Worker 1041C0700X Primary
Naturopath 175F00000X
Peer Specialist 175T00000X

Addresses

Primary practice location

637 Barneswyck Dr
Fuquay Varina, NC 27526-2277

Mailing address

637 Barneswyck Dr
Fuquay Varina, NC 27526-2277

National Provider Directory

National Provider Directory

Practitioners & affiliated clinicians

Practitioners 3

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles, and the practitioner matching its NPPES authorized official.

NPI Registry JSON

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

{
    "created_epoch": "1710979200000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1710979200000",
    "number": "1942060215",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "637 BARNESWYCK DR",
            "city": "FUQUAY VARINA",
            "state": "NC",
            "postal_code": "275262277"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "637 BARNESWYCK DR",
            "city": "FUQUAY VARINA",
            "state": "NC",
            "postal_code": "275262277",
            "telephone_number": "919-839-9721"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "MODERN MYSTICS, LLC",
        "organizational_subpart": "NO",
        "enumeration_date": "2024-03-21",
        "last_updated": "2024-03-21",
        "certification_date": "2024-03-21",
        "status": "A",
        "authorized_official_last_name": "FAHY",
        "authorized_official_first_name": "SHANNON",
        "authorized_official_title_or_position": "FOUNDER/CEO",
        "authorized_official_telephone_number": "919-839-9721",
        "authorized_official_credential": "LCSW"
    },
    "taxonomies": [
        {
            "code": "101YA0400X",
            "taxonomy_group": "",
            "desc": "Counselor, Addiction (Substance Use Disorder)",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "code": "101YM0800X",
            "taxonomy_group": "",
            "desc": "Counselor, Mental Health",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "code": "1041C0700X",
            "taxonomy_group": "",
            "desc": "Social Worker, Clinical",
            "state": null,
            "license": null,
            "primary": true
        },
        {
            "code": "175F00000X",
            "taxonomy_group": "",
            "desc": "Naturopath",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "code": "175T00000X",
            "taxonomy_group": "",
            "desc": "Peer Specialist",
            "state": null,
            "license": null,
            "primary": false
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

Other providers in Fuquay Varina, NC

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Mar 21, 2024; 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.