Provider Demographics
NPI:1881459436
Name:MODISETTE, MARY
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:
Last Name:MODISETTE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:59 MUCKELEMI ST APT 102
Mailing Address - Street 2:
Mailing Address - City:SAN JUAN BAUTISTA
Mailing Address - State:CA
Mailing Address - Zip Code:95045-9335
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:611 ABBOTT ST STE 101
Practice Address - Street 2:
Practice Address - City:SALINAS
Practice Address - State:CA
Practice Address - Zip Code:93901-4391
Practice Address - Country:US
Practice Address - Phone:831-757-3041
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-02-13
Last Update Date:2024-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA10408225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist