Healthcare Provider Details

I. General information

NPI: 1093079212
Provider Name (Legal Business Name): AGAVE STUDIO FOR PSYCHOTHERAPY AND SPIRITUAL DIRECTION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/02/2012
Last Update Date: 07/02/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2950 W CHICAGO AVE #302
CHICAGO IL
60622-4375
US

IV. Provider business mailing address

1333 N ARTESIAN AVE # 2
CHICAGO IL
60622-2935
US

V. Phone/Fax

Practice location:
  • Phone: 773-627-2112
  • Fax:
Mailing address:
  • Phone: 773-627-2112
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code101YP1600X
TaxonomyPastoral Counselor
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number071.008116
License Number StateIL

VIII. Authorized Official

Name: DR. JANEIL IRENE RUIZ
Title or Position: EXECUTIVE DIRECTOR AND FOUNDER
Credential: PSY.D.
Phone: 773-627-2112