Provider Demographics
NPI:1619920980
Name:MODARESI, HEIDAR A (PHD)
Entity Type:Individual
Prefix:DR
First Name:HEIDAR
Middle Name:A
Last Name:MODARESI
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 1:3060 WIMBLEDON LN
Mailing Address - Street 2:
Mailing Address - City:ROCK HILL
Mailing Address - State:SC
Mailing Address - Zip Code:29732-9249
Mailing Address - Country:US
Mailing Address - Phone:803-366-9791
Mailing Address - Fax:803-753-9522
Practice Address - Street 1:3060 WIMBLEDON LN
Practice Address - Street 2:
Practice Address - City:ROCK HILL
Practice Address - State:SC
Practice Address - Zip Code:29732-9249
Practice Address - Country:US
Practice Address - Phone:803-366-9791
Practice Address - Fax:803-753-9522
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-18
Last Update Date:2010-09-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC1973101YM0800X, 103TB0200X, 103TC0700X, 103T00000X
SC0575101YM0800X, 103TB0200X, 103TC0700X, 103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No103TB0200XBehavioral Health & Social Service ProvidersPsychologistCognitive & Behavioral
No103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCPS0221Medicaid
SCPS0221Medicaid