Provider Demographics
NPI:1528748464
Name:MODLIN, BROOKE FULSCHER (LICSW)
Entity type:Individual
Prefix:
First Name:BROOKE
Middle Name:FULSCHER
Last Name:MODLIN
Suffix:
Gender:F
Credentials:LICSW
Other - Prefix:MRS
Other - First Name:BROOKE
Other - Middle Name:FULSCHER
Other - Last Name:MODLIN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:622 JEFFERSON ST S
Mailing Address - Street 2:
Mailing Address - City:LEWISBURG
Mailing Address - State:WV
Mailing Address - Zip Code:24901-2016
Mailing Address - Country:US
Mailing Address - Phone:303-523-9052
Mailing Address - Fax:
Practice Address - Street 1:1464 JEFFERSON ST N
Practice Address - Street 2:
Practice Address - City:LEWISBURG
Practice Address - State:WV
Practice Address - Zip Code:24901-1380
Practice Address - Country:US
Practice Address - Phone:303-523-9052
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-07-24
Last Update Date:2023-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WVDP009462411041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical