Provider Demographics
NPI:1659474096
Name:GLEZAKOS, AGATHI (PHD LCSW)
Entity Type:Individual
Prefix:DR
First Name:AGATHI
Middle Name:
Last Name:GLEZAKOS
Suffix:
Gender:F
Credentials:PHD LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:27596 HOMESTEAD RD
Mailing Address - Street 2:
Mailing Address - City:LAGUNA NIGUEL
Mailing Address - State:CA
Mailing Address - Zip Code:92677-6602
Mailing Address - Country:US
Mailing Address - Phone:714-642-1621
Mailing Address - Fax:562-985-5514
Practice Address - Street 1:27596 HOMESTEAD RD
Practice Address - Street 2:
Practice Address - City:LAGUNA NIGUEL
Practice Address - State:CA
Practice Address - Zip Code:92677-6602
Practice Address - Country:US
Practice Address - Phone:714-642-1621
Practice Address - Fax:562-985-5514
Is Sole Proprietor?:No
Enumeration Date:2006-09-07
Last Update Date:2023-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CALCSW5432101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAZZZ83022ZOtherBLUE SHIELD OF CA
KY0007495215OtherAETNA
CACSW05432Medicaid
CAZZZ83022ZOtherBLUE SHIELD OF CA