Provider Demographics
NPI:1952507204
Name:DIVINAGRACIA, AGNES THERESE ENOPIA (PT)
Entity type:Individual
Prefix:MRS
First Name:AGNES THERESE
Middle Name:ENOPIA
Last Name:DIVINAGRACIA
Suffix:
Gender:F
Credentials:PT
Other - Prefix:MISS
Other - First Name:AGNES
Other - Middle Name:G
Other - Last Name:ENOPIA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PT
Mailing Address - Street 1:3227 BEL PRE RD
Mailing Address - Street 2:
Mailing Address - City:SILVER SPRING
Mailing Address - State:MD
Mailing Address - Zip Code:20906-2423
Mailing Address - Country:US
Mailing Address - Phone:417-437-4395
Mailing Address - Fax:
Practice Address - Street 1:3227 BEL PRE RD
Practice Address - Street 2:
Practice Address - City:SILVER SPRING
Practice Address - State:MD
Practice Address - Zip Code:20906-2423
Practice Address - Country:US
Practice Address - Phone:417-437-4395
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-06-25
Last Update Date:2012-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD22164225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist