Provider Demographics
NPI:1376126763
Name:MODOSKI, MARK E (LCSW-C)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:E
Last Name:MODOSKI
Suffix:
Gender:M
Credentials:LCSW-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2700 WILLOW OAK DR APT 112
Mailing Address - Street 2:
Mailing Address - City:CAMBRIDGE
Mailing Address - State:MD
Mailing Address - Zip Code:21613-3539
Mailing Address - Country:US
Mailing Address - Phone:443-521-9525
Mailing Address - Fax:
Practice Address - Street 1:2700 WILLOW OAK DR APT 112
Practice Address - Street 2:
Practice Address - City:CAMBRIDGE
Practice Address - State:MD
Practice Address - Zip Code:21613-3539
Practice Address - Country:US
Practice Address - Phone:443-521-9525
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-05-03
Last Update Date:2021-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ37LC00298800101YA0400X
MD27003101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)