1205163847 NPI number — CHARLOTTE MODAHL PH.D.

Table of content: CHARLOTTE MODAHL PH.D. (NPI 1205163847)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1205163847 NPI number — CHARLOTTE MODAHL PH.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MODAHL
Provider First Name:
CHARLOTTE
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
PH.D.
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1205163847
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
11/04/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3121 W COAST HWY
Provider Second Line Business Mailing Address:
3A
Provider Business Mailing Address City Name:
NEWPORT BEACH
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
92663-4022
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
949-642-2041
Provider Business Mailing Address Fax Number:
949-642-2076

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1601 BALL RD
Provider Second Line Business Practice Location Address:
#304
Provider Business Practice Location Address City Name:
CYPRESS
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
90630
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
562-431-8822
Provider Business Practice Location Address Fax Number:
562-431-8875
Provider Enumeration Date:
11/03/2009

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 103TC0700X , with the licence number:  PSY10375 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: CP103750 . This is a "MEDICARE" identifier . This identifiers is of the category "OTHER".




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