Provider Demographics
NPI:1881003705
Name:MARK MODLIN, INC.
Entity Type:Organization
Organization Name:MARK MODLIN, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:MARK
Authorized Official - Middle Name:ALAN
Authorized Official - Last Name:MODLIN
Authorized Official - Suffix:
Authorized Official - Credentials:MS, NCC
Authorized Official - Phone:859-341-7170
Mailing Address - Street 1:130 DUDLEY PIKE
Mailing Address - Street 2:SUITE 120
Mailing Address - City:EDGEWOOD
Mailing Address - State:KY
Mailing Address - Zip Code:41017-2396
Mailing Address - Country:US
Mailing Address - Phone:859-341-7170
Mailing Address - Fax:859-341-7173
Practice Address - Street 1:130 DUDLEY PIKE
Practice Address - Street 2:SUITE 120
Practice Address - City:EDGEWOOD
Practice Address - State:KY
Practice Address - Zip Code:41017-2396
Practice Address - Country:US
Practice Address - Phone:859-341-7170
Practice Address - Fax:859-341-7173
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-08-05
Last Update Date:2014-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYKY-0206101Y00000X, 101YA0400X, 101YM0800X
OHC.0001640101Y00000X, 101YA0400X, 101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselorGroup - Multi-Specialty
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Multi-Specialty
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty