Provider Demographics
NPI:1750511036
Name:MODLIN, AMY (LMSW, CAADC)
Entity Type:Individual
Prefix:
First Name:AMY
Middle Name:
Last Name:MODLIN
Suffix:
Gender:F
Credentials:LMSW, CAADC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:401 WEST FULTON ST
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49504
Mailing Address - Country:US
Mailing Address - Phone:616-610-0591
Mailing Address - Fax:
Practice Address - Street 1:401 WEST FULTON ST
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49504
Practice Address - Country:US
Practice Address - Phone:616-610-0591
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-07-21
Last Update Date:2023-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NH20281041C0700X
MI68010907151041C0700X
CA1066911041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical