MEDICARE: AGAPE COUNSELING & THERAPEUTIC SERVICES, INC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101Y00000X	Counselor
2	101YA0400X	Addiction (Substance Use Disorder) Counselor
3	101YM0800X	Mental Health Counselor	0904004904	VA
4	101YP2500X	Professional Counselor
5	103TC0700X	Clinical Psychologist
6	103TH0004X	Health Psychologist
7	104100000X	Social Worker
8	1041C0700X	Clinical Social Worker	0904004904	VA
9	1041C0700X	Clinical Social Worker	0904002584	VA
10	1041C0700X	Clinical Social Worker
11	172V00000X	Community Health Worker
12	251S00000X	Community/Behavioral Health Agency	0904004904	VA
13	261QM0855X	Adolescent and Children Mental Health Clinic/Center
14	251S00000X	Community/Behavioral Health Agency

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	Q59697C284	OTHER	VA	MEDICARE PTAN
6	Q46363C284	OTHER	VA	MEDICARE PTAN

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
2	13953971	OTHER	VA	CAQH
3	11526769	OTHER	VA	CAQH
4	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
5	Q42793C284	OTHER	VA	MEDICAARE PTAN

General Provider Information

NPI Number	:	1134148380
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	AGAPE COUNSELING & THERAPEUTIC SERVICES, INC

Provider Business Mailing Address
First Line	:	3221 COMMANDER SHEPARD BLVD
Second Line	:
City	:	HAMPTON
State	:	VA
Zip	:	23666-1598
Country	:	US
Telephone Number	:	757-244-3500
Fax Number	:	877-468-5361

Provider Business Practice Location Address
First Line	:	3221 COMMANDER SHEPARD BLVD
Second Line	:
City	:	HAMPTON
State	:	VA
Zip	:	23666-1598
Country	:	US
Telephone Number	:	757-244-3500
Fax Number	:	877-468-5361

Authorized Official
Title or Position	:	CREDENTIALING SPEC
Name	:	TEISHA SPARROW
Credential	:
Telephone Number	:	757-244-3500

Provider Enumeration Date	:	07/19/2006
Last Update Date	:	02/08/2021

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