Provider Demographics
NPI:1114573904
Name:AGAMA, CARLA ESTEFANY I
Entity type:Individual
Prefix:MISS
First Name:CARLA
Middle Name:ESTEFANY
Last Name:AGAMA
Suffix:I
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6125 97TH ST APT 6R
Mailing Address - Street 2:
Mailing Address - City:REGO PARK
Mailing Address - State:NY
Mailing Address - Zip Code:11374-1231
Mailing Address - Country:US
Mailing Address - Phone:347-833-1099
Mailing Address - Fax:
Practice Address - Street 1:225 BROADHOLLOW RD STE 402
Practice Address - Street 2:
Practice Address - City:MELVILLE
Practice Address - State:NY
Practice Address - Zip Code:11747-4899
Practice Address - Country:US
Practice Address - Phone:631-385-7780
Practice Address - Fax:631-385-7795
Is Sole Proprietor?:No
Enumeration Date:2019-08-16
Last Update Date:2019-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician