MEDICARE: SONYA MODKINS

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	101YA0400X	Addiction (Substance Use Disorder) Counselor	13574	TX

General Provider Information

NPI Number	:	1497534408
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SONYA MODKINS

Provider Business Mailing Address
First Line	:	2307 SPRINGLAKE RD STE 500
Second Line	:
City	:	FARMERS BRANCH
State	:	TX
Zip	:	75234-5876
Country	:	US
Telephone Number	:	469-291-5288
Fax Number	:	469-291-5443

Provider Business Practice Location Address
First Line	:	2831 TRAILDUST DR
Second Line	:
City	:	DALLAS
State	:	TX
Zip	:	75237-3223
Country	:	US
Telephone Number	:	214-229-1775
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/28/2023
Last Update Date	:	09/28/2023

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