Healthcare Provider Details

I. General information

NPI: 1548345465
Provider Name (Legal Business Name): MARIA AGIT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/26/2006
Last Update Date: 07/08/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

409 DUDLEY ST
ROXBURY MA
02119-3366
US

IV. Provider business mailing address

69 THORNTON RD
CHESTNUT HILL MA
02467-3616
US

V. Phone/Fax

Practice location:
  • Phone: 617-427-7175
  • Fax: 617-427-5209
Mailing address:
  • Phone: 617-327-2420
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number6099
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: