Provider Demographics
NPI:1740541465
Name:AGOSTA, STACEY (MS ED, BCBA)
Entity type:Individual
Prefix:MISS
First Name:STACEY
Middle Name:
Last Name:AGOSTA
Suffix:
Gender:F
Credentials:MS ED, BCBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:80 HAUPPAUGE RD
Mailing Address - Street 2:
Mailing Address - City:COMMACK
Mailing Address - State:NY
Mailing Address - Zip Code:11725-4403
Mailing Address - Country:US
Mailing Address - Phone:631-462-0386
Mailing Address - Fax:
Practice Address - Street 1:80 HAUPPAUGE RD
Practice Address - Street 2:
Practice Address - City:COMMACK
Practice Address - State:NY
Practice Address - Zip Code:11725-4403
Practice Address - Country:US
Practice Address - Phone:631-462-0386
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-05-30
Last Update Date:2012-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY1118752103K00000X
NY174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
No103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst