Provider Demographics
NPI:1316960958
Name:MODEL, DANIEL R (PSY)
Entity type:Individual
Prefix:
First Name:DANIEL
Middle Name:R
Last Name:MODEL
Suffix:
Gender:
Credentials:PSY
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1080 EMELINE AVE
Mailing Address - Street 2:
Mailing Address - City:SANTA CRUZ
Mailing Address - State:CA
Mailing Address - Zip Code:95060-1966
Mailing Address - Country:US
Mailing Address - Phone:831-454-4100
Mailing Address - Fax:831-454-4488
Practice Address - Street 1:1080 EMELINE AVE
Practice Address - Street 2:
Practice Address - City:SANTA CRUZ
Practice Address - State:CA
Practice Address - Zip Code:95060-1966
Practice Address - Country:US
Practice Address - Phone:831-454-4100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-25
Last Update Date:2025-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY 19315103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPSY 19315OtherLICENSE #
CAZZZ92073ZOtherMEDICARE GROUP ID#
CAZZZ92069ZOtherMEDICARE GROUP ID#
CAZZZ91891ZOtherMEDICARE GROUP ID#
CAZZZ91892ZOtherMEDICARE GROUP ID#
CAQ38893Medicare UPIN
CAOPL193150Medicare PIN