Provider Demographics
NPI:1023580727
Name:AGRA, IRENE MARIE
Entity Type:Individual
Prefix:MRS
First Name:IRENE
Middle Name:MARIE
Last Name:AGRA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:IRENE
Other - Middle Name:MARIE
Other - Last Name:PEREZ
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:3425 COFFEE RD STE C2
Mailing Address - Street 2:
Mailing Address - City:MODESTO
Mailing Address - State:CA
Mailing Address - Zip Code:95355-1582
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1300 ETHAN WAY STE 175
Practice Address - Street 2:
Practice Address - City:SACRAMENTO
Practice Address - State:CA
Practice Address - Zip Code:95825-2277
Practice Address - Country:US
Practice Address - Phone:209-521-4791
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-12-19
Last Update Date:2018-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician