Provider Demographics
NPI:1831736362
Name:WOLDAN-LOPEZ, AGATA G (LCSW)
Entity type:Individual
Prefix:MRS
First Name:AGATA
Middle Name:G
Last Name:WOLDAN-LOPEZ
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5230 39TH DR APT 11A
Mailing Address - Street 2:
Mailing Address - City:WOODSIDE
Mailing Address - State:NY
Mailing Address - Zip Code:11377-4021
Mailing Address - Country:US
Mailing Address - Phone:646-623-3242
Mailing Address - Fax:
Practice Address - Street 1:1 GUSTAVE L LEVY PL FL 12
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10029-6574
Practice Address - Country:US
Practice Address - Phone:212-420-2358
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-12-03
Last Update Date:2019-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0721931041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical