Provider Demographics
NPI:1164216370
Name:AGNEW, TAE'A LASHEA (SUDRC)
Entity type:Individual
Prefix:MISS
First Name:TAE'A
Middle Name:LASHEA
Last Name:AGNEW
Suffix:
Gender:F
Credentials:SUDRC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:39485 SALINAS DR
Mailing Address - Street 2:
Mailing Address - City:MURRIETA
Mailing Address - State:CA
Mailing Address - Zip Code:92563-6819
Mailing Address - Country:US
Mailing Address - Phone:760-718-9350
Mailing Address - Fax:
Practice Address - Street 1:200 E WASHINGTON AVE STE 100
Practice Address - Street 2:
Practice Address - City:ESCONDIDO
Practice Address - State:CA
Practice Address - Zip Code:92025-1806
Practice Address - Country:US
Practice Address - Phone:760-741-7708
Practice Address - Fax:760-741-5421
Is Sole Proprietor?:Yes
Enumeration Date:2025-04-04
Last Update Date:2025-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA21053101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Multi-Specialty