Provider Demographics
NPI:1457237331
Name:MODRICH, ANDREW
Entity type:Individual
Prefix:
First Name:ANDREW
Middle Name:
Last Name:MODRICH
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:815 CEDAR ST
Mailing Address - Street 2:
Mailing Address - City:VALLEJO
Mailing Address - State:CA
Mailing Address - Zip Code:94591-6531
Mailing Address - Country:US
Mailing Address - Phone:707-556-8640
Mailing Address - Fax:
Practice Address - Street 1:815 CEDAR ST
Practice Address - Street 2:
Practice Address - City:VALLEJO
Practice Address - State:CA
Practice Address - Zip Code:94591-6531
Practice Address - Country:US
Practice Address - Phone:707-556-8640
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-08-14
Last Update Date:2025-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
225800000X
CA968AED3373171400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171400000XOther Service ProvidersHealth & Wellness Coach
No225800000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRecreation Therapist