Provider Demographics
NPI:1255194437
Name:AGOSTO, REBECCA A
Entity type:Individual
Prefix:
First Name:REBECCA
Middle Name:A
Last Name:AGOSTO
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 1:1727 N OCEAN AVE
Mailing Address - Street 2:
Mailing Address - City:MEDFORD
Mailing Address - State:NY
Mailing Address - Zip Code:11763-2649
Mailing Address - Country:US
Mailing Address - Phone:631-578-0652
Mailing Address - Fax:
Practice Address - Street 1:1727 N OCEAN AVE
Practice Address - Street 2:
Practice Address - City:MEDFORD
Practice Address - State:NY
Practice Address - Zip Code:11763-2649
Practice Address - Country:US
Practice Address - Phone:631-578-0652
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-01-31
Last Update Date:2024-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY122788-01104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker