Provider Demographics
NPI:1053643429
Name:MODENBACH, RICHARD YOUNG (LCSW)
Entity Type:Individual
Prefix:MR
First Name:RICHARD
Middle Name:YOUNG
Last Name:MODENBACH
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:744 W 9TH ST
Mailing Address - Street 2:8TH FLOOR
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74127-9020
Mailing Address - Country:US
Mailing Address - Phone:918-599-5730
Mailing Address - Fax:918-599-5859
Practice Address - Street 1:744 W 9TH ST
Practice Address - Street 2:8TH FLOOR
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74127-9020
Practice Address - Country:US
Practice Address - Phone:918-599-5730
Practice Address - Fax:918-599-5859
Is Sole Proprietor?:No
Enumeration Date:2010-02-09
Last Update Date:2010-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK18911041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical