Healthcare Provider Details

I. General information

NPI: 1780403501
Provider Name (Legal Business Name): AGAVE MEDICAL NY, P.C
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/08/2024
Last Update Date: 03/13/2025
Certification Date: 03/13/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

16397 ROAD 37
MADERA CA
93636-8224
US

IV. Provider business mailing address

359 5TH ST UNIT 3
JERSEY CITY NJ
07302-2329
US

V. Phone/Fax

Practice location:
  • Phone: 510-871-5025
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code103TH0004X
TaxonomyHealth Psychologist
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code104100000X
TaxonomySocial Worker
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number
License Number State

VIII. Authorized Official

Name: MICHAEL SCAHILL
Title or Position: CEO
Credential:
Phone: 510-871-5025