Provider Demographics
NPI:1265570121
Name:MCCONLOGUE, AGNES M (MAPT)
Entity type:Individual
Prefix:
First Name:AGNES
Middle Name:M
Last Name:MCCONLOGUE
Suffix:
Gender:F
Credentials:MAPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2 HUYLER CT
Mailing Address - Street 2:
Mailing Address - City:SETAUKET
Mailing Address - State:NY
Mailing Address - Zip Code:11733-1308
Mailing Address - Country:US
Mailing Address - Phone:631-751-7968
Mailing Address - Fax:
Practice Address - Street 1:252 ISLIP AVE
Practice Address - Street 2:
Practice Address - City:ISLIP
Practice Address - State:NY
Practice Address - Zip Code:11751-3015
Practice Address - Country:US
Practice Address - Phone:631-581-6800
Practice Address - Fax:631-581-6814
Is Sole Proprietor?:No
Enumeration Date:2007-02-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY013987174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist