Provider Demographics
NPI:1629113568
Name:MODESTO, PAUL (PHD)
Entity Type:Individual
Prefix:DR
First Name:PAUL
Middle Name:
Last Name:MODESTO
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 1:5301 N FEDERAL HWY
Mailing Address - Street 2:SUITE 270
Mailing Address - City:BOCA RATON
Mailing Address - State:FL
Mailing Address - Zip Code:33487-4910
Mailing Address - Country:US
Mailing Address - Phone:561-241-6628
Mailing Address - Fax:561-241-8651
Practice Address - Street 1:5301 N FEDERAL HWY
Practice Address - Street 2:SUITE 270
Practice Address - City:BOCA RATON
Practice Address - State:FL
Practice Address - Zip Code:33487-4910
Practice Address - Country:US
Practice Address - Phone:561-241-6628
Practice Address - Fax:561-241-8651
Is Sole Proprietor?:No
Enumeration Date:2007-02-20
Last Update Date:2011-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPY2368103TC0700X
FLMT857106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL75624BMedicare ID - Type Unspecified
R99991Medicare UPIN