Provider Demographics
NPI:1326165010
Name:MODLIN, SUSAN W (LCSW)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:W
Last Name:MODLIN
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 1:130 CARBONTON RD
Mailing Address - Street 2:
Mailing Address - City:SANFORD
Mailing Address - State:NC
Mailing Address - Zip Code:27330-4009
Mailing Address - Country:US
Mailing Address - Phone:919-774-6521
Mailing Address - Fax:919-776-6179
Practice Address - Street 1:130 CARBONTON RD
Practice Address - Street 2:
Practice Address - City:SANFORD
Practice Address - State:NC
Practice Address - Zip Code:27330-4009
Practice Address - Country:US
Practice Address - Phone:919-774-6521
Practice Address - Fax:919-776-6179
Is Sole Proprietor?:No
Enumeration Date:2007-03-26
Last Update Date:2013-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC6007202Medicaid
NC2860170Medicare PIN