Provider Demographics
NPI:1487238382
Name:AGNE, MISTY LYNN (CCC-SLP)
Entity type:Individual
Prefix:
First Name:MISTY
Middle Name:LYNN
Last Name:AGNE
Suffix:
Gender:F
Credentials:CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4912 US HIGHWAY 42 STE 104
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40222-6357
Mailing Address - Country:US
Mailing Address - Phone:502-429-8640
Mailing Address - Fax:502-426-2283
Practice Address - Street 1:4912 US HIGHWAY 42 STE 104
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40222-6357
Practice Address - Country:US
Practice Address - Phone:502-429-8640
Practice Address - Fax:502-426-2283
Is Sole Proprietor?:No
Enumeration Date:2021-05-07
Last Update Date:2021-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY137731235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist