Provider Demographics
NPI:1255346011
Name:OSTERHOLT-POLSTON, AGNES CECILIA (MSW,LCSWS)
Entity type:Individual
Prefix:
First Name:AGNES
Middle Name:CECILIA
Last Name:OSTERHOLT-POLSTON
Suffix:
Gender:F
Credentials:MSW,LCSWS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4235 FLAGSTAFF COVE
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46815
Mailing Address - Country:US
Mailing Address - Phone:260-969-6600
Mailing Address - Fax:260-969-6601
Practice Address - Street 1:4235 FLAGSTAFF COVE
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46815
Practice Address - Country:US
Practice Address - Phone:260-969-6600
Practice Address - Fax:260-969-6601
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-30
Last Update Date:2014-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN34002679A1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical