Healthcare Provider Details

I. General information

NPI: 1215652334
Provider Name (Legal Business Name): DAVID M MODLIN MSW, LCSW
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/11/2022
Last Update Date: 09/23/2026
Certification Date: 09/23/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

MEDICAL CENTER BOULEVARD
WINSTON SALEM NC
27157-0001
US

IV. Provider business mailing address

100 KIMEL FOREST DR
WINSTON SALEM NC
27103-6074
US

V. Phone/Fax

Practice location:
  • Phone: 336-716-1029
  • Fax: 336-713-6342
Mailing address:
  • Phone: 336-713-0947
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberC019677
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: