Provider Demographics
NPI:1861224719
Name:MODESTO, ASHLEY CHANNELLE
Entity type:Individual
Prefix:
First Name:ASHLEY
Middle Name:CHANNELLE
Last Name:MODESTO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1305 IDLEWILD BLVD
Mailing Address - Street 2:
Mailing Address - City:FREDERICKSBURG
Mailing Address - State:VA
Mailing Address - Zip Code:22401-6603
Mailing Address - Country:US
Mailing Address - Phone:407-276-2135
Mailing Address - Fax:
Practice Address - Street 1:31 STAFFORD AVE
Practice Address - Street 2:
Practice Address - City:STAFFORD
Practice Address - State:VA
Practice Address - Zip Code:22554-7246
Practice Address - Country:US
Practice Address - Phone:540-658-6000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-08-19
Last Update Date:2024-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041S0200XBehavioral Health & Social Service ProvidersSocial WorkerSchool