Basic Information
Provider Information
NPI: 1144661158
EntityType: 1
ReplacementNPI:  
OrganizationName:  
LastName: AGOSTO
FirstName: STACY
MiddleName: L
NamePrefix:  
NameSuffix:  
Credential: LCSW
OtherOrganizationName:  
OtherOrganizationType:  
OtherLastName:  
OtherFirstName:  
OtherMiddleName:  
OtherNamePrefix:  
OtherNameSuffix:  
OtherCredential:  
OtherLastNameType:  
Mailing Information
Address1: 109 CALIFORNIA ST
Address2: PO BOX 577
City: CARTERVILLE
State: IL
PostalCode: 629180577
CountryCode: US
TelephoneNumber: 6185199200
FaxNumber: 6189854635
Practice Location
Address1: 400 S LEWIS LN
Address2:  
City: CARBONDALE
State: IL
PostalCode: 62901
CountryCode: US
TelephoneNumber: 6185199200
FaxNumber: 6185199961
Other Information
ProviderEnumerationDate: 07/08/2013
LastUpdateDate: 10/05/2018
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode: F
AuthorizedOfficialLastName:  
AuthorizedOfficialFirstName:  
AuthorizedOfficialMiddleName:  
AuthorizedOfficialTitleorPosition:  
AuthorizedOfficialTelephone:  
IsSoleProprietor: N
IsOrganizationSubpart:  
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix:  
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential:  
NPICertificationDate:  

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
1041C0700X149016461ILY Behavioral Health & Social Service ProvidersSocial WorkerClinical

No ID Information.


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