Provider Demographics
NPI:1093985384
Name:MODIN, STANISLAV
Entity Type:Individual
Prefix:MR
First Name:STANISLAV
Middle Name:
Last Name:MODIN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1318 N ORANGE DR APT 303
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90028-7571
Mailing Address - Country:US
Mailing Address - Phone:323-962-4493
Mailing Address - Fax:
Practice Address - Street 1:1318 N ORANGE DR APT 303
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90028-7571
Practice Address - Country:US
Practice Address - Phone:323-962-4493
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-03-03
Last Update Date:2008-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)