Provider Demographics
NPI:1083273411
Name:AGNEW, CHARLENE NICOLE (MA)
Entity Type:Individual
Prefix:
First Name:CHARLENE
Middle Name:NICOLE
Last Name:AGNEW
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3559 164TH ST APT RH
Mailing Address - Street 2:
Mailing Address - City:FLUSHING
Mailing Address - State:NY
Mailing Address - Zip Code:11358-1729
Mailing Address - Country:US
Mailing Address - Phone:917-442-4900
Mailing Address - Fax:
Practice Address - Street 1:3559 164TH ST APT RH
Practice Address - Street 2:
Practice Address - City:FLUSHING
Practice Address - State:NY
Practice Address - Zip Code:11358-1729
Practice Address - Country:US
Practice Address - Phone:917-442-4900
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-06-10
Last Update Date:2019-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY001738103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst