Provider Demographics
NPI:1205163847
Name:MODAHL, CHARLOTTE (PHD)
Entity type:Individual
Prefix:
First Name:CHARLOTTE
Middle Name:
Last Name:MODAHL
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3121 W COAST HWY
Mailing Address - Street 2:3A
Mailing Address - City:NEWPORT BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:92663-4022
Mailing Address - Country:US
Mailing Address - Phone:949-642-2041
Mailing Address - Fax:949-642-2076
Practice Address - Street 1:1601 BALL RD
Practice Address - Street 2:#304
Practice Address - City:CYPRESS
Practice Address - State:CA
Practice Address - Zip Code:90630
Practice Address - Country:US
Practice Address - Phone:562-431-8822
Practice Address - Fax:562-431-8875
Is Sole Proprietor?:Yes
Enumeration Date:2009-11-03
Last Update Date:2010-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY10375103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CP103750OtherMEDICARE