Provider Demographics
NPI:1417762360
Name:SYLVERIN, AGNES STEPHANIE (LMT)
Entity type:Individual
Prefix:
First Name:AGNES
Middle Name:STEPHANIE
Last Name:SYLVERIN
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2165 RUGBY AVE APT 436
Mailing Address - Street 2:
Mailing Address - City:COLLEGE PARK
Mailing Address - State:GA
Mailing Address - Zip Code:30337-1036
Mailing Address - Country:US
Mailing Address - Phone:770-855-9755
Mailing Address - Fax:
Practice Address - Street 1:1800 JONESBORO RD SE FL 4
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30315-5314
Practice Address - Country:US
Practice Address - Phone:678-515-4974
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-02-10
Last Update Date:2025-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAMT009089225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist