Provider Demographics
NPI:1508958976
Name:AGUSTINOVICH, PAUL MARTIN (PHD)
Entity Type:Individual
Prefix:DR
First Name:PAUL
Middle Name:MARTIN
Last Name:AGUSTINOVICH
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:501 1ST AVE
Mailing Address - Street 2:STE. 1A
Mailing Address - City:SAN MATEO
Mailing Address - State:CA
Mailing Address - Zip Code:94401-3213
Mailing Address - Country:US
Mailing Address - Phone:650-348-0755
Mailing Address - Fax:650-685-6618
Practice Address - Street 1:501 1ST AVE
Practice Address - Street 2:STE. 1A
Practice Address - City:SAN MATEO
Practice Address - State:CA
Practice Address - Zip Code:94401-3213
Practice Address - Country:US
Practice Address - Phone:650-348-0755
Practice Address - Fax:650-685-6618
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMFC32652106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist