Healthcare Provider Details

I. General information

NPI: 1477005809
Provider Name (Legal Business Name): ANDREA AGAJANIAN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/02/2016
Last Update Date: 07/21/2025
Certification Date: 07/21/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3670 W SHORE RD UNIT 5
WARWICK RI
02886-5028
US

IV. Provider business mailing address

3670 W SHORE RD UNIT 5
WARWICK RI
02886-5028
US

V. Phone/Fax

Practice location:
  • Phone: 401-712-0411
  • Fax:
Mailing address:
  • Phone: 401-712-0411
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number11643
License Number StateMA
# 2
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberMHC01106
License Number StateRI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: