Healthcare Provider Details

I. General information

NPI: 1568370260
Provider Name (Legal Business Name): PETER AGDAMAG JR.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/01/2026
Last Update Date: 09/01/2026
Certification Date: 09/01/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

87003 PROFESSIONAL WAY
YULEE FL
32097-3400
US

IV. Provider business mailing address

227 W LAUREL BLF
KINGSLAND GA
31548-6183
US

V. Phone/Fax

Practice location:
  • Phone: 904-849-1190
  • Fax:
Mailing address:
  • Phone: 919-426-6886
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberIMH29543
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: