=====================================================
General NPI Number Information
=====================================================
NPI Number | 1184910580
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | AGNIESZKA APOLONIA HORNICH PSY.D.
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/23/2011
-----------------------------------------------------
Last Update Date | 06/23/2011
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1540 SPRING VALLEY DR
-----------------------------------------------------
City | HUNTINGTON
-----------------------------------------------------
State | WV
-----------------------------------------------------
Zip | 25704-9300
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 304-429-6755
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 12 JAMES DR
-----------------------------------------------------
City | HUNTINGTON
-----------------------------------------------------
State | WV
-----------------------------------------------------
Zip | 25705-2353
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 304-208-3425
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 103TC0700X
-----------------------------------------------------
Taxonomy Name | Clinical Psychologist
-----------------------------------------------------
License Number | 1019
-----------------------------------------------------
License Number State | WV
-----------------------------------------------------