Provider Demographics
NPI:1790820272
Name:AGNEW, DALE R (LISW-S, LCDC-III)
Entity Type:Individual
Prefix:
First Name:DALE
Middle Name:R
Last Name:AGNEW
Suffix:
Gender:M
Credentials:LISW-S, LCDC-III
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:222 S WEST ST
Mailing Address - Street 2:
Mailing Address - City:LIMA
Mailing Address - State:OH
Mailing Address - Zip Code:45801-4842
Mailing Address - Country:US
Mailing Address - Phone:419-222-7180
Mailing Address - Fax:419-228-8439
Practice Address - Street 1:222 S WEST ST
Practice Address - Street 2:
Practice Address - City:LIMA
Practice Address - State:OH
Practice Address - Zip Code:45801-4842
Practice Address - Country:US
Practice Address - Phone:419-222-7180
Practice Address - Fax:419-228-8439
Is Sole Proprietor?:No
Enumeration Date:2007-02-21
Last Update Date:2010-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHI.0009680101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health