Provider Demographics
NPI:1780099705
Name:MODLIN, COLE (MA)
Entity type:Individual
Prefix:MR
First Name:COLE
Middle Name:
Last Name:MODLIN
Suffix:
Gender:M
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7950 CRYSTAL CREEK CIR
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76137-5624
Mailing Address - Country:US
Mailing Address - Phone:682-999-8186
Mailing Address - Fax:682-747-6887
Practice Address - Street 1:609 CHEEK SPARGER RD STE 112
Practice Address - Street 2:
Practice Address - City:COLLEYVILLE
Practice Address - State:TX
Practice Address - Zip Code:76034-3856
Practice Address - Country:US
Practice Address - Phone:682-999-8186
Practice Address - Fax:682-747-6887
Is Sole Proprietor?:Yes
Enumeration Date:2014-06-27
Last Update Date:2020-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX68664101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional