Basic Information
| Provider Information | |||||||||
| NPI: | 1699276550 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MODESITT | ||||||||
| FirstName: | PAUL | ||||||||
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| Credential: | CADC1 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 706 MAIN ST | ||||||||
| Address2: | |||||||||
| City: | OREGON CITY | ||||||||
| State: | OR | ||||||||
| PostalCode: | 970451815 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5036551029 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 900 MAIN ST STE 200 | ||||||||
| Address2: | |||||||||
| City: | OREGON CITY | ||||||||
| State: | OR | ||||||||
| PostalCode: | 970451869 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9713863401 | ||||||||
| FaxNumber: | 5037236653 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/26/2018 | ||||||||
| LastUpdateDate: | 01/06/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 01/06/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YA0400X | OR | Y | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) | 175T00000X | 17-CRM-187 | OR | N |
No ID Information.