Provider Demographics
NPI:1326895251
Name:AGOSTO, SURAIJA (LAC)
Entity type:Individual
Prefix:MS
First Name:SURAIJA
Middle Name:
Last Name:AGOSTO
Suffix:
Gender:F
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:388 HUGUENOT AVE
Mailing Address - Street 2:
Mailing Address - City:UNION
Mailing Address - State:NJ
Mailing Address - Zip Code:07083-7557
Mailing Address - Country:US
Mailing Address - Phone:718-924-9935
Mailing Address - Fax:
Practice Address - Street 1:121 CHANLON RD
Practice Address - Street 2:
Practice Address - City:NEW PROVIDENCE
Practice Address - State:NJ
Practice Address - Zip Code:07974-1543
Practice Address - Country:US
Practice Address - Phone:973-299-9954
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-04-30
Last Update Date:2024-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
1485225600000X
NJ37AC00643500101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No225600000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDance Therapist