Provider Demographics
NPI:1588025605
Name:D'AGOSTINO, MARCIE
Entity Type:Individual
Prefix:
First Name:MARCIE
Middle Name:
Last Name:D'AGOSTINO
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 1:5003 EL NUEVA AVE
Mailing Address - Street 2:
Mailing Address - City:FORT PIERCE
Mailing Address - State:FL
Mailing Address - Zip Code:34946-1093
Mailing Address - Country:US
Mailing Address - Phone:914-261-3792
Mailing Address - Fax:
Practice Address - Street 1:5003 EL NUEVA AVE
Practice Address - Street 2:
Practice Address - City:FORT PIERCE
Practice Address - State:FL
Practice Address - Zip Code:34946-1093
Practice Address - Country:US
Practice Address - Phone:914-261-3792
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-03-17
Last Update Date:2023-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMH14081101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health