Provider Demographics
NPI:1962510255
Name:MODELL, PATRICIA ANN (LCSW)
Entity Type:Individual
Prefix:MRS
First Name:PATRICIA
Middle Name:ANN
Last Name:MODELL
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5225 NO IRONWOOD ROAD
Mailing Address - Street 2:STRESS MANAGEMENT
Mailing Address - City:GLENDALE
Mailing Address - State:WI
Mailing Address - Zip Code:53217
Mailing Address - Country:US
Mailing Address - Phone:414-962-9156
Mailing Address - Fax:414-962-4356
Practice Address - Street 1:5225 NORTH IRONWOOD RD.
Practice Address - Street 2:SUITE 102
Practice Address - City:GLENDALE
Practice Address - State:WI
Practice Address - Zip Code:53217
Practice Address - Country:US
Practice Address - Phone:414-962-9156
Practice Address - Fax:414-962-4356
Is Sole Proprietor?:No
Enumeration Date:2006-08-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI3008123LCSW104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI40963800Medicaid