Basic Information
| Provider Information | |||||||||
| NPI: | 1760019566 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MODICA | ||||||||
| FirstName: | CHRISTYN | ||||||||
| MiddleName: | DON | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1747 SW COZY LN | ||||||||
| Address2: | |||||||||
| City: | PORT ORCHARD | ||||||||
| State: | WA | ||||||||
| PostalCode: | 983679321 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3605360018 | ||||||||
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| Practice Location | |||||||||
| Address1: | 4210 20TH ST E STE B&C | ||||||||
| Address2: | |||||||||
| City: | FIFE | ||||||||
| State: | WA | ||||||||
| PostalCode: | 984241830 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2532355216 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 03/24/2020 | ||||||||
| LastUpdateDate: | 09/14/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 09/14/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101Y00000X | CG61019299 | WA | N | Behavioral Health & Social Service Providers | Counselor | 101YA0400X | CP60771150 | WA | N | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) | 101Y00000X | MC61140763 | WA | Y | Behavioral Health & Social Service Providers | Counselor |
ID Information
| ID | Type | State | Issuer | Description | CG61019299 | 01 | WA | COUNSELOR AGENCY AFFILIATED REGISTRATION | OTHER |