Provider Demographics
NPI:1801170956
Name:MODICA, MARIAELENA (LCSW)
Entity type:Individual
Prefix:
First Name:MARIAELENA
Middle Name:
Last Name:MODICA
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 1:30 UPTON ST
Mailing Address - Street 2:
Mailing Address - City:STATEN ISLAND
Mailing Address - State:NY
Mailing Address - Zip Code:10304-3108
Mailing Address - Country:US
Mailing Address - Phone:347-539-7692
Mailing Address - Fax:
Practice Address - Street 1:2381 HYLAN BLVD
Practice Address - Street 2:
Practice Address - City:STATEN ISLAND
Practice Address - State:NY
Practice Address - Zip Code:10306-3122
Practice Address - Country:US
Practice Address - Phone:800-277-4680
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-10-07
Last Update Date:2022-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY080977-01104100000X, 1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker