Provider Demographics
NPI:1760019566
Name:MODICA, CHRISTYN DON
Entity Type:Individual
Prefix:
First Name:CHRISTYN
Middle Name:DON
Last Name:MODICA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1747 SW COZY LN
Mailing Address - Street 2:
Mailing Address - City:PORT ORCHARD
Mailing Address - State:WA
Mailing Address - Zip Code:98367-9321
Mailing Address - Country:US
Mailing Address - Phone:360-536-0018
Mailing Address - Fax:
Practice Address - Street 1:4210 20TH ST E STE B&C
Practice Address - Street 2:
Practice Address - City:FIFE
Practice Address - State:WA
Practice Address - Zip Code:98424-1830
Practice Address - Country:US
Practice Address - Phone:253-235-5216
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-03-24
Last Update Date:2021-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WACG61019299101Y00000X
WACP60771150101YA0400X
WAMC61140763101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
WACG61019299OtherCOUNSELOR AGENCY AFFILIATED REGISTRATION