Provider Demographics
NPI:1912626136
Name:FRYE-PATCH, MODENA
Entity Type:Individual
Prefix:MS
First Name:MODENA
Middle Name:
Last Name:FRYE-PATCH
Suffix:
Gender:F
Credentials:
Other - Prefix:MS
Other - First Name:MODENA
Other - Middle Name:
Other - Last Name:FRYE
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:1007 W LEXINGTON AVE
Mailing Address - Street 2:
Mailing Address - City:POMONA
Mailing Address - State:CA
Mailing Address - Zip Code:91766-5056
Mailing Address - Country:US
Mailing Address - Phone:909-455-7685
Mailing Address - Fax:
Practice Address - Street 1:303 W MANCHESTER BLVD STE 207
Practice Address - Street 2:
Practice Address - City:INGLEWOOD
Practice Address - State:CA
Practice Address - Zip Code:90301-1154
Practice Address - Country:US
Practice Address - Phone:213-926-1100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-08-22
Last Update Date:2022-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAAMFT99116106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist