Provider Demographics
NPI:1659702363
Name:TIMBERGER, AGNES (LISCENSED MASTER SOC)
Entity Type:Individual
Prefix:
First Name:AGNES
Middle Name:
Last Name:TIMBERGER
Suffix:
Gender:F
Credentials:LISCENSED MASTER SOC
Other - Prefix:
Other - First Name:AGNES
Other - Middle Name:
Other - Last Name:MONTALVO TIMBERGER
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 330
Mailing Address - Street 2:
Mailing Address - City:SLATE HILL
Mailing Address - State:NY
Mailing Address - Zip Code:10973-0330
Mailing Address - Country:US
Mailing Address - Phone:845-978-7979
Mailing Address - Fax:845-355-7929
Practice Address - Street 1:626 EATONTOWN ROAD
Practice Address - Street 2:
Practice Address - City:PORT JERVIS
Practice Address - State:NY
Practice Address - Zip Code:12771
Practice Address - Country:US
Practice Address - Phone:845-978-7979
Practice Address - Fax:845-355-7929
Is Sole Proprietor?:Yes
Enumeration Date:2013-12-05
Last Update Date:2020-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY039221-1104100000X
NY089546-011041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker