Provider Demographics
NPI:1639552078
Name:MODAFFARI, SUNNI M (LPC)
Entity Type:Individual
Prefix:
First Name:SUNNI
Middle Name:M
Last Name:MODAFFARI
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:66 CLUB RD STE 120
Mailing Address - Street 2:
Mailing Address - City:EUGENE
Mailing Address - State:OR
Mailing Address - Zip Code:97401-2439
Mailing Address - Country:US
Mailing Address - Phone:541-393-5983
Mailing Address - Fax:541-393-5984
Practice Address - Street 1:4185 SW RESEARCH WAY
Practice Address - Street 2:
Practice Address - City:CORVALLIS
Practice Address - State:OR
Practice Address - Zip Code:97333-1783
Practice Address - Country:US
Practice Address - Phone:541-257-5500
Practice Address - Fax:541-286-4140
Is Sole Proprietor?:No
Enumeration Date:2015-07-02
Last Update Date:2020-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
14076568OtherCAQH
OR500691014Medicaid