Provider Demographics
NPI:1912404328
Name:AGATE DYNAMICS, LLC
Entity Type:Organization
Organization Name:AGATE DYNAMICS, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MICHELLE
Authorized Official - Middle Name:
Authorized Official - Last Name:AULT
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:505-361-1958
Mailing Address - Street 1:1201 EUBANK BLVD NE STE 1
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87112-5300
Mailing Address - Country:US
Mailing Address - Phone:505-361-1958
Mailing Address - Fax:505-369-1951
Practice Address - Street 1:1201 EUBANK BLVD NE STE 1
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87112-5300
Practice Address - Country:US
Practice Address - Phone:505-361-1958
Practice Address - Fax:505-369-1951
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-04-11
Last Update Date:2018-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty