Provider Demographics
NPI:1205133550
Name:GOBIC, AGATA H (MSW, CSW)
Entity type:Individual
Prefix:
First Name:AGATA
Middle Name:H
Last Name:GOBIC
Suffix:
Gender:F
Credentials:MSW, CSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4924 BRYWILL CIR
Mailing Address - Street 2:
Mailing Address - City:SARASOTA
Mailing Address - State:FL
Mailing Address - Zip Code:34234-3725
Mailing Address - Country:US
Mailing Address - Phone:941-228-4643
Mailing Address - Fax:
Practice Address - Street 1:1748 INDEPENDENCE BLVD STE D1
Practice Address - Street 2:
Practice Address - City:SARASOTA
Practice Address - State:FL
Practice Address - Zip Code:34234-2151
Practice Address - Country:US
Practice Address - Phone:941-359-1927
Practice Address - Fax:941-359-1929
Is Sole Proprietor?:Yes
Enumeration Date:2011-02-23
Last Update Date:2011-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSWI62881041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLSWI6288Medicaid