Healthcare Provider Details

I. General information

NPI: 1023427861
Provider Name (Legal Business Name): AGAVE STUDIO, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/06/2014
Last Update Date: 08/12/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2950 W CHICAGO AVE SUITE 202
CHICAGO IL
60622-4375
US

IV. Provider business mailing address

2950 W CHICAGO AVE SUITE 202
CHICAGO IL
60622-4375
US

V. Phone/Fax

Practice location:
  • Phone: 618-444-8801
  • Fax:
Mailing address:
  • Phone: 618-444-8801
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number180008030
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number071.008116
License Number StateIL

VIII. Authorized Official

Name: MRS. AMANDA G BULL
Title or Position: BILLING DIRECTOR, STAFF THERAPIST
Credential: MA, LCPC
Phone: 618-444-8801