Healthcare Provider Details

I. General information

NPI: 1922394824
Provider Name (Legal Business Name): AGNIESZKA SMITH
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: AGNIESZKA MATUSIAK

II. Dates (important events)

Enumeration Date: 06/20/2011
Last Update Date: 12/22/2020
Certification Date: 12/22/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

24 GARDINER ST
RICHMOND ME
04357-1336
US

IV. Provider business mailing address

24 GARDINER ST
RICHMOND ME
04357-1336
US

V. Phone/Fax

Practice location:
  • Phone: 207-737-4359
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberMC10926
License Number StateME

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: