Provider Demographics
NPI:1497868590
Name:AGNEW, CAROL S (LMFT)
Entity type:Individual
Prefix:
First Name:CAROL
Middle Name:S
Last Name:AGNEW
Suffix:
Gender:F
Credentials:LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:42627 GARFIELD RD STE 217
Mailing Address - Street 2:
Mailing Address - City:CLINTON TOWNSHIP
Mailing Address - State:MI
Mailing Address - Zip Code:48038-5032
Mailing Address - Country:US
Mailing Address - Phone:248-210-5018
Mailing Address - Fax:
Practice Address - Street 1:42627 GARFIELD RD STE 217
Practice Address - Street 2:
Practice Address - City:CLINTON TOWNSHIP
Practice Address - State:MI
Practice Address - Zip Code:48038-5032
Practice Address - Country:US
Practice Address - Phone:248-210-5018
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-16
Last Update Date:2019-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4101006139101YM0800X, 106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
12458685OtherCAQH