Healthcare Provider Details

I. General information

NPI: 1659234664
Provider Name (Legal Business Name): CAROL MODDELMOG
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/05/2025
Last Update Date: 12/22/2025
Certification Date: 12/22/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1700 E IRON AVE
SALINA KS
67401-3401
US

IV. Provider business mailing address

1700 E IRON AVE
SALINA KS
67401-3401
US

V. Phone/Fax

Practice location:
  • Phone: 785-825-3029
  • Fax:
Mailing address:
  • Phone: 785-655-0541
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number
License Number State

VIII. Authorized Official

Name: MRS. CAROL MODDELMOG
Title or Position: THERAPIST
Credential: LCMFT
Phone: 785-655-0541