Provider Demographics
NPI:1356509442
Name:AGOSTA, LYDIA ELLEN
Entity Type:Individual
Prefix:
First Name:LYDIA
Middle Name:ELLEN
Last Name:AGOSTA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:LYDIA
Other - Middle Name:ELLEN
Other - Last Name:GOWIE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2336 GODDARD PKWY
Mailing Address - Street 2:
Mailing Address - City:SALISBURY
Mailing Address - State:MD
Mailing Address - Zip Code:21801-1126
Mailing Address - Country:US
Mailing Address - Phone:410-334-6961
Mailing Address - Fax:410-334-6960
Practice Address - Street 1:2336 GODDARD PKWY
Practice Address - Street 2:
Practice Address - City:SALISBURY
Practice Address - State:MD
Practice Address - Zip Code:21801-1126
Practice Address - Country:US
Practice Address - Phone:410-334-6961
Practice Address - Fax:410-334-6960
Is Sole Proprietor?:No
Enumeration Date:2008-05-27
Last Update Date:2013-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD609500303Medicaid
MD609500300Medicaid