Provider Demographics
NPI:1639224645
Name:AGAR, MATILDA CATHY (LCSW)
Entity Type:Individual
Prefix:
First Name:MATILDA
Middle Name:CATHY
Last Name:AGAR
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3385 MOHEGAN AVE
Mailing Address - Street 2:
Mailing Address - City:MOHEGAN LAKE
Mailing Address - State:NY
Mailing Address - Zip Code:10547-1317
Mailing Address - Country:US
Mailing Address - Phone:914-526-2740
Mailing Address - Fax:
Practice Address - Street 1:1 GATEWAY PLZ
Practice Address - Street 2:401
Practice Address - City:PORT CHESTER
Practice Address - State:NY
Practice Address - Zip Code:10573-4674
Practice Address - Country:US
Practice Address - Phone:914-872-5290
Practice Address - Fax:914-948-0299
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYRO33684-11041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYN6B011Medicare ID - Type Unspecified