Provider Demographics
NPI:1336504190
Name:MODAK, DANIELLE NICOLE (DPT)
Entity Type:Individual
Prefix:MRS
First Name:DANIELLE
Middle Name:NICOLE
Last Name:MODAK
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:DANIELLE
Other - Middle Name:NICOLE
Other - Last Name:GOULET
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 1975
Mailing Address - Street 2:
Mailing Address - City:ROME
Mailing Address - State:GA
Mailing Address - Zip Code:30162-1975
Mailing Address - Country:US
Mailing Address - Phone:386-873-7590
Mailing Address - Fax:866-237-9650
Practice Address - Street 1:113 W CHIPOLA AVE STE 219
Practice Address - Street 2:
Practice Address - City:DELAND
Practice Address - State:FL
Practice Address - Zip Code:32720-7512
Practice Address - Country:US
Practice Address - Phone:386-873-7590
Practice Address - Fax:866-237-9650
Is Sole Proprietor?:No
Enumeration Date:2015-12-22
Last Update Date:2015-12-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPT30674225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist