Provider Demographics
NPI:1326316514
Name:MODRAK, BEVIN JAY (LCPC)
Entity Type:Individual
Prefix:MR
First Name:BEVIN
Middle Name:JAY
Last Name:MODRAK
Suffix:
Gender:M
Credentials:LCPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:6568 S FEDERAL WAY
Mailing Address - Street 2:#124
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83716-9277
Mailing Address - Country:US
Mailing Address - Phone:208-283-9710
Mailing Address - Fax:208-319-7773
Practice Address - Street 1:204 S COLE RD
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83709-0934
Practice Address - Country:US
Practice Address - Phone:208-319-9786
Practice Address - Fax:208-319-7773
Is Sole Proprietor?:Yes
Enumeration Date:2011-12-02
Last Update Date:2023-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDLCPC4698101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health