Provider Demographics
NPI:1205877057
Name:DIGIACOMO, AGNES
Entity type:Individual
Prefix:
First Name:AGNES
Middle Name:
Last Name:DIGIACOMO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2600 POST RD
Mailing Address - Street 2:
Mailing Address - City:SOUTHPORT
Mailing Address - State:CT
Mailing Address - Zip Code:06890-1258
Mailing Address - Country:US
Mailing Address - Phone:203-256-3338
Mailing Address - Fax:
Practice Address - Street 1:2600 POST RD
Practice Address - Street 2:
Practice Address - City:SOUTHPORT
Practice Address - State:CT
Practice Address - Zip Code:06890-1258
Practice Address - Country:US
Practice Address - Phone:203-256-3338
Practice Address - Fax:203-256-3346
Is Sole Proprietor?:No
Enumeration Date:2006-06-10
Last Update Date:2022-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ41YA00061000231H00000X
CT000467231H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes231H00000XSpeech, Language and Hearing Service ProvidersAudiologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ7121300Medicaid
CT000467OtherLICENSE