Provider Demographics
NPI:1699276550
Name:MODESITT, PAUL (CADC1)
Entity type:Individual
Prefix:
First Name:PAUL
Middle Name:
Last Name:MODESITT
Suffix:
Gender:M
Credentials:CADC1
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:706 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:OREGON CITY
Mailing Address - State:OR
Mailing Address - Zip Code:97045-1815
Mailing Address - Country:US
Mailing Address - Phone:503-655-1029
Mailing Address - Fax:
Practice Address - Street 1:900 MAIN ST STE 200
Practice Address - Street 2:
Practice Address - City:OREGON CITY
Practice Address - State:OR
Practice Address - Zip Code:97045-1869
Practice Address - Country:US
Practice Address - Phone:971-386-3401
Practice Address - Fax:503-723-6653
Is Sole Proprietor?:No
Enumeration Date:2018-02-26
Last Update Date:2022-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR101YA0400X
OR17-CRM-187175T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No175T00000XOther Service ProvidersPeer Specialist