Provider Demographics
NPI:1477750685
Name:MODESTO, ANICE ROBINSON (PHD)
Entity Type:Individual
Prefix:DR
First Name:ANICE
Middle Name:ROBINSON
Last Name:MODESTO
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5828 HAYMARKET RD
Mailing Address - Street 2:
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38120-3011
Mailing Address - Country:US
Mailing Address - Phone:901-820-0033
Mailing Address - Fax:
Practice Address - Street 1:214 WILDER TOWER
Practice Address - Street 2:UNIVERSITY OF MEMPHIS, CCL&T
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38152-3520
Practice Address - Country:US
Practice Address - Phone:901-678-2068
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-29
Last Update Date:2007-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNP1152103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist