Healthcare Provider Details

I. General information

NPI: 1578358081
Provider Name (Legal Business Name): NOAH RAE MODESTO
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/14/2025
Last Update Date: 04/14/2025
Certification Date: 04/14/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

48 ELM ST
WORCESTER MA
01609-2541
US

IV. Provider business mailing address

3 WALNUT ST
UPTON MA
01568-1101
US

V. Phone/Fax

Practice location:
  • Phone: 800-337-5965
  • Fax:
Mailing address:
  • Phone: 508-686-6957
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number State

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: