Provider Demographics
NPI:1699859926
Name:MODELL, EUGENE ALBERT (PHD)
Entity Type:Individual
Prefix:DR
First Name:EUGENE
Middle Name:ALBERT
Last Name:MODELL
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 1:1601 CARMEN DR
Mailing Address - Street 2:STE 211
Mailing Address - City:CAMARILLO
Mailing Address - State:CA
Mailing Address - Zip Code:93010-3103
Mailing Address - Country:US
Mailing Address - Phone:805-987-3727
Mailing Address - Fax:805-484-0356
Practice Address - Street 1:1601 CARMEN DR
Practice Address - Street 2:STE 211
Practice Address - City:CAMARILLO
Practice Address - State:CA
Practice Address - Zip Code:93010-3103
Practice Address - Country:US
Practice Address - Phone:805-987-3727
Practice Address - Fax:805-484-0356
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-24
Last Update Date:2016-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY 5021103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical