Provider Demographics
NPI:1326897216
Name:AGNEW, OLIVIA LEIGH
Entity type:Individual
Prefix:
First Name:OLIVIA
Middle Name:LEIGH
Last Name:AGNEW
Suffix:
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 1:7237 CORKLAN DR APT 1536
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32258-2659
Mailing Address - Country:US
Mailing Address - Phone:217-565-0766
Mailing Address - Fax:
Practice Address - Street 1:495 PROSPERITY LAKE DR STE 101
Practice Address - Street 2:
Practice Address - City:SAINT AUGUSTINE
Practice Address - State:FL
Practice Address - Zip Code:32092-5045
Practice Address - Country:US
Practice Address - Phone:904-370-3420
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-05-14
Last Update Date:2024-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health