Provider Demographics
NPI:1134490709
Name:MODINE, CHRISTY (LCSW)
Entity Type:Individual
Prefix:
First Name:CHRISTY
Middle Name:
Last Name:MODINE
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:70 LEY ST
Mailing Address - Street 2:
Mailing Address - City:NEW HAVEN
Mailing Address - State:CT
Mailing Address - Zip Code:06512-3920
Mailing Address - Country:US
Mailing Address - Phone:203-466-2306
Mailing Address - Fax:
Practice Address - Street 1:10 SCHOOL ST
Practice Address - Street 2:
Practice Address - City:MADISON
Practice Address - State:CT
Practice Address - Zip Code:06443-3033
Practice Address - Country:US
Practice Address - Phone:203-245-5645
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-01-13
Last Update Date:2012-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT0073291041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical