Provider Demographics
NPI:1326177411
Name:MODZELEWSKI, TRISHA ANN (LMHC)
Entity Type:Individual
Prefix:
First Name:TRISHA
Middle Name:ANN
Last Name:MODZELEWSKI
Suffix:
Gender:F
Credentials:LMHC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8570 STIRLING RD STE 102-105
Mailing Address - Street 2:
Mailing Address - City:HOLLYWOOD
Mailing Address - State:FL
Mailing Address - Zip Code:33024-8203
Mailing Address - Country:US
Mailing Address - Phone:954-756-5491
Mailing Address - Fax:
Practice Address - Street 1:9703 NW 16TH ST
Practice Address - Street 2:
Practice Address - City:PEMBROKE PINES
Practice Address - State:FL
Practice Address - Zip Code:33024-4474
Practice Address - Country:US
Practice Address - Phone:954-756-5491
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-05
Last Update Date:2023-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMH71231041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL768056200Medicaid