1013139716 NPI number — DR. AGNELO B DIAS ED. D., LCSW

Table of content: DR. AGNELO B DIAS ED. D., LCSW (NPI 1013139716)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1013139716 NPI number — DR. AGNELO B DIAS ED. D., LCSW

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
DIAS
Provider First Name:
AGNELO
Provider Middle Name:
B
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
ED. D., LCSW
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1013139716
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
11/16/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
595 DOGWOOD AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
WEST HEMPSTEAD
Provider Business Mailing Address State Name:
NY
Provider Business Mailing Address Postal Code:
11552-3128
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
516-414-1953
Provider Business Mailing Address Fax Number:
516-414-1953

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2174 HEWLETT AVE
Provider Second Line Business Practice Location Address:
SUITE 212
Provider Business Practice Location Address City Name:
MERRICK
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
11566-3606
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
516-513-2678
Provider Business Practice Location Address Fax Number:
516-414-1953
Provider Enumeration Date:
05/03/2007

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 1041C0700X , with the licence number:  73 079925 , registered in the state of NY ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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