Provider Demographics
NPI:1679650048
Name:AGAMEZ, MONA HIBBERT (OTR/L)
Entity Type:Individual
Prefix:MRS
First Name:MONA
Middle Name:HIBBERT
Last Name:AGAMEZ
Suffix:
Gender:F
Credentials:OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:90 W 500 S # 315
Mailing Address - Street 2:
Mailing Address - City:BOUNTIFUL
Mailing Address - State:UT
Mailing Address - Zip Code:84010-6230
Mailing Address - Country:US
Mailing Address - Phone:702-499-3841
Mailing Address - Fax:877-296-8903
Practice Address - Street 1:90 W 500 S # 315
Practice Address - Street 2:
Practice Address - City:BOUNTIFUL
Practice Address - State:UT
Practice Address - Zip Code:84010-6230
Practice Address - Country:US
Practice Address - Phone:702-499-3841
Practice Address - Fax:877-296-8903
Is Sole Proprietor?:No
Enumeration Date:2006-11-01
Last Update Date:2013-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV0470225X00000X, 225XP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
No225XP0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV003402366Medicaid