Organization
MODERN PSYCHOLOGIST NETWORK LLC
Active
Other names
Advanced Life Innovations PLLC
Organization subpart
No
Provider details
NPI number
Authorized official
BARON CRESPO PSY.D. (CLINICAL & FORENSIC PSYCHOLOGIST)
(305) 249-1694
Entity
Organization
Contact information
Practice address
16 E AVENUE A STE 212, TEMPLE, TX 76501
(305) 249-1694
(305) 647-6045
Mailing address
463 WESTFIELD BLVD APT 121, TEMPLE, TX 76502-5319
Taxonomy
Speciality
Code
Description
License number
State
103T00000X
Psychologist
Primary
37853
TX
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
381189501
—
TX
01
—
631971
MEDICARE
TX
Enumeration date
01/24/2015
Last updated
08/10/2018
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