Healthcare Provider Details

I. General information

NPI: 1740905124
Provider Name (Legal Business Name): DANIEL MODLINGER
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/07/2022
Last Update Date: 08/31/2023
Certification Date: 08/31/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

489 POST RD E FL 2
WESTPORT CT
06880-4435
US

IV. Provider business mailing address

489 POST RD E FL 2
WESTPORT CT
06880-4435
US

V. Phone/Fax

Practice location:
  • Phone: 203-429-4190
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number12300
License Number StateCT
# 2
Primary TaxonomyN
Taxonomy Code146N00000X
TaxonomyBasic Emergency Medical Technician
License Number20186
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: