MEDICARE: MODRELL CLINICAL SERVICES LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1041C0700X	Clinical Social Worker

General Provider Information

NPI Number	:	1396439345
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MODRELL CLINICAL SERVICES LLC

Provider Business Mailing Address
First Line	:	1201 WAKARUSA DR STE E107
Second Line	:
City	:	LAWRENCE
State	:	KS
Zip	:	66049-3913
Country	:	US
Telephone Number	:	913-662-3627
Fax Number	:

Provider Business Practice Location Address
First Line	:	1201 WAKARUSA DR STE E107
Second Line	:
City	:	LAWRENCE
State	:	KS
Zip	:	66049-3913
Country	:	US
Telephone Number	:	913-662-3627
Fax Number	:

Authorized Official
Title or Position	:	CLINICAL SOCIAL WORKER
Name	:	JUSTIN MODRELL
Credential	:	LSCSW
Telephone Number	:	913-662-3627

Provider Enumeration Date	:	06/05/2023
Last Update Date	:	06/05/2023

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Directions to “MODRELL CLINICAL SERVICES LLC ” Practice Location

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