Provider Demographics
NPI:1619637402
Name:AGNEW, GREGORY WILLIAM (LAC, LMT)
Entity Type:Individual
Prefix:MR
First Name:GREGORY
Middle Name:WILLIAM
Last Name:AGNEW
Suffix:
Gender:M
Credentials:LAC, LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 31
Mailing Address - Street 2:
Mailing Address - City:BAYVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:11709-0031
Mailing Address - Country:US
Mailing Address - Phone:516-857-3723
Mailing Address - Fax:
Practice Address - Street 1:23 GREEN ST STE 100A
Practice Address - Street 2:
Practice Address - City:HUNTINGTON
Practice Address - State:NY
Practice Address - Zip Code:11743-3336
Practice Address - Country:US
Practice Address - Phone:516-857-3723
Practice Address - Fax:516-674-9031
Is Sole Proprietor?:Yes
Enumeration Date:2021-12-21
Last Update Date:2023-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY019277225700000X
NY007033171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist
No225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist