Healthcare Provider Details

I. General information

NPI: 1235308925
Provider Name (Legal Business Name): KIMBERLY C AGRESTA LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/27/2008
Last Update Date: 02/27/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

547 MAIN STREET
HACKENSACK NJ
07601
US

IV. Provider business mailing address

4 BLACKLEDGE CT
CLOSTER NJ
07624
US

V. Phone/Fax

Practice location:
  • Phone: 201-784-6718
  • Fax:
Mailing address:
  • Phone: 201-784-6718
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number44SC05347700
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: