Provider Demographics
NPI:1942597331
Name:LASETCHUK, AGNES M (LCSW)
Entity Type:Individual
Prefix:MS
First Name:AGNES
Middle Name:M
Last Name:LASETCHUK
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:225 MAIN ST.
Mailing Address - Street 2:
Mailing Address - City:PORT WASHINGTON
Mailing Address - State:NY
Mailing Address - Zip Code:11050-3211
Mailing Address - Country:US
Mailing Address - Phone:516-767-1133
Mailing Address - Fax:516-767-3680
Practice Address - Street 1:225 MAIN ST.
Practice Address - Street 2:
Practice Address - City:PORT WASHINGTON
Practice Address - State:NY
Practice Address - Zip Code:11050-3211
Practice Address - Country:US
Practice Address - Phone:516-767-1133
Practice Address - Fax:516-767-3680
Is Sole Proprietor?:No
Enumeration Date:2011-07-06
Last Update Date:2011-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYP022983-1101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)