Healthcare Provider Details

I. General information

NPI: 1346791787
Provider Name (Legal Business Name): ELIZABETH MODICLAN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/20/2016
Last Update Date: 02/04/2026
Certification Date: 02/04/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

160 OSBORN ST
FALL RIVER MA
02724-2814
US

IV. Provider business mailing address

51 HAWTHORNE ST
NORTH PROVIDENCE RI
02904-3816
US

V. Phone/Fax

Practice location:
  • Phone: 508-676-5708
  • Fax:
Mailing address:
  • Phone: 814-386-4565
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: