Provider Demographics
NPI:1699832881
Name:AUGUSTINE, ANN TYSON (LICSW)
Entity type:Individual
Prefix:
First Name:ANN
Middle Name:TYSON
Last Name:AUGUSTINE
Suffix:
Gender:F
Credentials:LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:143 HIGH ST
Mailing Address - Street 2:
Mailing Address - City:AMHERST
Mailing Address - State:MA
Mailing Address - Zip Code:01002-1853
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:50 PLEASANT ST
Practice Address - Street 2:
Practice Address - City:NORTHAMPTON
Practice Address - State:MA
Practice Address - Zip Code:01060-3909
Practice Address - Country:US
Practice Address - Phone:413-584-6855
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-03
Last Update Date:2020-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA1119151041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAP23663Medicare ID - Type Unspecified