Healthcare Provider Details

I. General information

NPI: 1538080767
Provider Name (Legal Business Name): CARL NEILON MODESTE PHD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/23/2026
Last Update Date: 07/23/2026
Certification Date: 07/23/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

18 OAK ST UNIT 1477
BRENTWOOD CA
94513-7560
US

IV. Provider business mailing address

18 OAK ST UNIT 1477
BRENTWOOD CA
94513-7560
US

V. Phone/Fax

Practice location:
  • Phone: 510-408-7268
  • Fax:
Mailing address:
  • Phone: 510-408-7268
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number36762
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code103TA0400X
TaxonomyAddiction (Substance Use Disorder) Psychologist
License Number36762
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code103TB0200X
TaxonomyCognitive & Behavioral Psychologist
License Number36762
License Number StateCA
# 4
Primary TaxonomyY
Taxonomy Code103TM1800X
TaxonomyIntellectual & Developmental Disabilities Psychologist
License Number36762
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: