Provider Demographics
NPI:1346460862
Name:MODDERS, DAVID LAWERENCE (PHD)
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:LAWERENCE
Last Name:MODDERS
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5051 SE 110TH ST
Mailing Address - Street 2:
Mailing Address - City:BELLEVIEW
Mailing Address - State:FL
Mailing Address - Zip Code:34420-3115
Mailing Address - Country:US
Mailing Address - Phone:352-245-9157
Mailing Address - Fax:352-245-3031
Practice Address - Street 1:1050 OLD CAMP RD STE 100
Practice Address - Street 2:
Practice Address - City:THE VILLAGES
Practice Address - State:FL
Practice Address - Zip Code:32162-1762
Practice Address - Country:US
Practice Address - Phone:352-674-1760
Practice Address - Fax:352-674-8960
Is Sole Proprietor?:No
Enumeration Date:2007-04-26
Last Update Date:2020-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPY6041103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical