Provider Demographics
NPI:1396913497
Name:AGOSTA, ANTONINO JR (PSY D)
Entity type:Individual
Prefix:MR
First Name:ANTONINO
Middle Name:
Last Name:AGOSTA
Suffix:JR
Gender:M
Credentials:PSY D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1135 W UNIVERSITY DR
Mailing Address - Street 2:SUITE 315A
Mailing Address - City:ROCHESTER
Mailing Address - State:MI
Mailing Address - Zip Code:48307-1871
Mailing Address - Country:US
Mailing Address - Phone:248-413-5027
Mailing Address - Fax:248-412-5048
Practice Address - Street 1:1135 W UNIVERSITY DR
Practice Address - Street 2:SUITE 315A
Practice Address - City:ROCHESTER
Practice Address - State:MI
Practice Address - Zip Code:48307-1871
Practice Address - Country:US
Practice Address - Phone:248-413-5027
Practice Address - Fax:248-412-5048
Is Sole Proprietor?:Yes
Enumeration Date:2008-02-12
Last Update Date:2021-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6301015487103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical