Provider Demographics
NPI:1467825331
Name:AGUDELO, STEPHANY
Entity Type:Individual
Prefix:
First Name:STEPHANY
Middle Name:
Last Name:AGUDELO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:102 VERONA DIVE
Mailing Address - Street 2:
Mailing Address - City:HAVELOCK
Mailing Address - State:NC
Mailing Address - Zip Code:28532
Mailing Address - Country:US
Mailing Address - Phone:914-439-2409
Mailing Address - Fax:
Practice Address - Street 1:102 VERONA DIVE
Practice Address - Street 2:
Practice Address - City:HAVELOCK
Practice Address - State:NC
Practice Address - Zip Code:28532
Practice Address - Country:US
Practice Address - Phone:914-497-7912
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-11-02
Last Update Date:2015-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCP0100091041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical