Provider Demographics
NPI:1972644458
Name:BISSETT, AGNES ANNE (LMSW)
Entity type:Individual
Prefix:MS
First Name:AGNES
Middle Name:ANNE
Last Name:BISSETT
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:MS
Other - First Name:AGNES
Other - Middle Name:ANNE
Other - Last Name:GOULETTE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LMSW
Mailing Address - Street 1:1221 PINE GROVE AVE
Mailing Address - Street 2:
Mailing Address - City:PORT HURON
Mailing Address - State:MI
Mailing Address - Zip Code:48060-3511
Mailing Address - Country:US
Mailing Address - Phone:810-985-2614
Mailing Address - Fax:
Practice Address - Street 1:1209 RICHARDSON ST
Practice Address - Street 2:
Practice Address - City:PORT HURON
Practice Address - State:MI
Practice Address - Zip Code:48060-3548
Practice Address - Country:US
Practice Address - Phone:810-984-5156
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-02-09
Last Update Date:2008-09-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6437291041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
0M85900OtherMEDICARE GROUP PTAN
M85900021OtherMEDICARE PTAN