Healthcare Provider Details

I. General information

NPI: 1225581408
Provider Name (Legal Business Name): MARY ELIZABETH AGULO AU.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/25/2016
Last Update Date: 11/27/2023
Certification Date: 11/22/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

875 SOUTH ROUTE 31
CRYSTAL LAKE IL
60014-8190
US

IV. Provider business mailing address

875 SOUTH ROUTE 31
CRYSTAL LAKE IL
60014-8190
US

V. Phone/Fax

Practice location:
  • Phone: 779-220-5500
  • Fax: 779-220-5571
Mailing address:
  • Phone: 779-220-5500
  • Fax: 779-220-5571

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code231H00000X
TaxonomyAudiologist
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code231H00000X
TaxonomyAudiologist
License Number147.001604
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: