Provider Demographics
NPI:1205417896
Name:MODOCK, ANDRA (MA, LLPC, NCE)
Entity Type:Individual
Prefix:
First Name:ANDRA
Middle Name:
Last Name:MODOCK
Suffix:
Gender:F
Credentials:MA, LLPC, NCE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7415 HARRISON ST
Mailing Address - Street 2:
Mailing Address - City:WESTLAND
Mailing Address - State:MI
Mailing Address - Zip Code:48185-2629
Mailing Address - Country:US
Mailing Address - Phone:734-578-6019
Mailing Address - Fax:
Practice Address - Street 1:7415 HARRISON ST
Practice Address - Street 2:
Practice Address - City:WESTLAND
Practice Address - State:MI
Practice Address - Zip Code:48185-2629
Practice Address - Country:US
Practice Address - Phone:734-578-6019
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-04-15
Last Update Date:2021-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COLPCC.0018266101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional