Provider Demographics
NPI:1922394824
Name:SMITH, AGNIESZKA
Entity Type:Individual
Prefix:
First Name:AGNIESZKA
Middle Name:
Last Name:SMITH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:AGNIESZKA
Other - Middle Name:
Other - Last Name:MATUSIAK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:24 GARDINER ST
Mailing Address - Street 2:
Mailing Address - City:RICHMOND
Mailing Address - State:ME
Mailing Address - Zip Code:04357-1336
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:24 GARDINER ST
Practice Address - Street 2:
Practice Address - City:RICHMOND
Practice Address - State:ME
Practice Address - Zip Code:04357-1336
Practice Address - Country:US
Practice Address - Phone:207-737-4359
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-06-20
Last Update Date:2020-12-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEMC109261041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical