Provider Demographics
NPI:1780758243
Name:MARTIN, AGNES A (MED, CAGS)
Entity type:Individual
Prefix:
First Name:AGNES
Middle Name:A
Last Name:MARTIN
Suffix:
Gender:F
Credentials:MED, CAGS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 200193
Mailing Address - Street 2:
Mailing Address - City:MISSION HILL
Mailing Address - State:MA
Mailing Address - Zip Code:02120-0004
Mailing Address - Country:US
Mailing Address - Phone:617-688-3489
Mailing Address - Fax:
Practice Address - Street 1:71 ADAMS ST
Practice Address - Street 2:
Practice Address - City:MILTON
Practice Address - State:MA
Practice Address - Zip Code:02186-3431
Practice Address - Country:US
Practice Address - Phone:617-688-3489
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-17
Last Update Date:2018-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA365793103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool