Provider Demographics
NPI:1780683409
Name:PAUL MODESTO, PH.D.,P.A.
Entity Type:Organization
Organization Name:PAUL MODESTO, PH.D.,P.A.
Other - Org Name:PAUL KULCSAR,PH.D.
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:PSYCHOLOGIST
Authorized Official - Prefix:DR
Authorized Official - First Name:PAUL
Authorized Official - Middle Name:
Authorized Official - Last Name:MODESTO
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:561-241-6628
Mailing Address - Street 1:5301 N FEDERAL HWY
Mailing Address - Street 2:
Mailing Address - City:BOCA RATON
Mailing Address - State:FL
Mailing Address - Zip Code:33487-4910
Mailing Address - Country:US
Mailing Address - Phone:561-421-6628
Mailing Address - Fax:561-241-8651
Practice Address - Street 1:5301 N FEDERAL HWY
Practice Address - Street 2:
Practice Address - City:BOCA RATON
Practice Address - State:FL
Practice Address - Zip Code:33487-4917
Practice Address - Country:US
Practice Address - Phone:561-421-6628
Practice Address - Fax:561-241-8651
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-07-15
Last Update Date:2011-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPY2368103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL75624BMedicare PIN
FL75624BMedicare ID - Type Unspecified