Provider Demographics
NPI:1053474098
Name:AGNEW, ALLEN JOHN (CASAC NYS 13121)
Entity Type:Individual
Prefix:MR
First Name:ALLEN
Middle Name:JOHN
Last Name:AGNEW
Suffix:
Gender:M
Credentials:CASAC NYS 13121
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:512 HIGHLAND RD
Mailing Address - Street 2:
Mailing Address - City:ITHACA
Mailing Address - State:NY
Mailing Address - Zip Code:14850-2218
Mailing Address - Country:US
Mailing Address - Phone:607-257-4245
Mailing Address - Fax:
Practice Address - Street 1:201 E GREEN ST
Practice Address - Street 2:SUITE 500
Practice Address - City:ITHACA
Practice Address - State:NY
Practice Address - Zip Code:14850-5635
Practice Address - Country:US
Practice Address - Phone:607-274-6288
Practice Address - Fax:607-274-6280
Is Sole Proprietor?:No
Enumeration Date:2006-12-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYCASAC 13121101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)