Provider Demographics
NPI:1417375353
Name:MODLIN, MARK ALAN (MS)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:ALAN
Last Name:MODLIN
Suffix:
Gender:M
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:130 DUDLEY PIKE
Mailing Address - Street 2:SUITE 120
Mailing Address - City:EDGEWOOD
Mailing Address - State:KY
Mailing Address - Zip Code:41017-2396
Mailing Address - Country:US
Mailing Address - Phone:859-341-7170
Mailing Address - Fax:859-341-7173
Practice Address - Street 1:130 DUDLEY PIKE
Practice Address - Street 2:SUITE 120
Practice Address - City:EDGEWOOD
Practice Address - State:KY
Practice Address - Zip Code:41017-2396
Practice Address - Country:US
Practice Address - Phone:859-341-7170
Practice Address - Fax:859-341-7173
Is Sole Proprietor?:No
Enumeration Date:2014-03-28
Last Update Date:2014-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYKY-0206101Y00000X, 101YA0400X, 101YM0800X, 101YP2500X
OHC.0001640101Y00000X, 101YA0400X, 101YM0800X, 101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional