Provider Demographics
NPI:1659762441
Name:AGIUS, JOHNATHAN (LLP)
Entity Type:Individual
Prefix:
First Name:JOHNATHAN
Middle Name:
Last Name:AGIUS
Suffix:
Gender:M
Credentials:LLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1440 TORREY RD
Mailing Address - Street 2:STE E
Mailing Address - City:FENTON
Mailing Address - State:MI
Mailing Address - Zip Code:48430-1340
Mailing Address - Country:US
Mailing Address - Phone:810-210-4894
Mailing Address - Fax:
Practice Address - Street 1:1440 TORREY RD STE E
Practice Address - Street 2:
Practice Address - City:FENTON
Practice Address - State:MI
Practice Address - Zip Code:48430
Practice Address - Country:US
Practice Address - Phone:810-288-6652
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-02-15
Last Update Date:2018-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6301016217103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist