Provider Demographics
NPI:1386215358
Name:MODRESKY, MICHAEL (LMFT)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:
Last Name:MODRESKY
Suffix:
Gender:M
Credentials:LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 4663
Mailing Address - Street 2:
Mailing Address - City:VALLEY VILLAGE
Mailing Address - State:CA
Mailing Address - Zip Code:91617-0663
Mailing Address - Country:US
Mailing Address - Phone:323-739-4536
Mailing Address - Fax:
Practice Address - Street 1:5628 WILLOWCREST AVE
Practice Address - Street 2:
Practice Address - City:VALLEY VILLAGE
Practice Address - State:CA
Practice Address - Zip Code:91601-2119
Practice Address - Country:US
Practice Address - Phone:215-859-7607
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-07-09
Last Update Date:2025-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA129991106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist