Basic Information
| Provider Information | |||||||||
| NPI: | 1881958759 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MODICA | ||||||||
| FirstName: | CHRISTOPHER | ||||||||
| MiddleName: | ANTHONY | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | PH.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3645 N BRIARWOOD LN | ||||||||
| Address2: | SUITE A | ||||||||
| City: | MUNCIE | ||||||||
| State: | IN | ||||||||
| PostalCode: | 473045214 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7652895520 | ||||||||
| FaxNumber: | 7652895840 | ||||||||
| Practice Location | |||||||||
| Address1: | 3645 N BRIARWOOD LN | ||||||||
| Address2: | SUITE A | ||||||||
| City: | MUNCIE | ||||||||
| State: | IN | ||||||||
| PostalCode: | 473045214 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7652895520 | ||||||||
| FaxNumber: | 7652895840 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/26/2012 | ||||||||
| LastUpdateDate: | 06/26/2012 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103TC1900X | Y | Behavioral Health & Social Service Providers | Psychologist | Counseling |
No ID Information.