Healthcare Provider Details

I. General information

NPI: 1467064972
Provider Name (Legal Business Name): EDWARD JUSTIN MODESTINO PH.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/18/2020
Last Update Date: 06/16/2026
Certification Date: 06/16/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8 MEADOWBROOK LN
SOUTH EASTON MA
02375-1289
US

IV. Provider business mailing address

8 MEADOWBROOK LN
SOUTH EASTON MA
02375-1289
US

V. Phone/Fax

Practice location:
  • Phone: 508-258-9703
  • Fax:
Mailing address:
  • Phone: 781-975-2185
  • Fax: 781-341-4489

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberLMHC10002001
License Number StateMA
# 2
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberMHC01717
License Number StateRI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: