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General NPI Number Information
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NPI Number | 1023427861
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Entity Type | Organization
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Legal Business Name | AGAVE STUDIO, LLC
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Dates
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Enumeration Date | 08/06/2014
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Last Update Date | 08/12/2014
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Provider Practice Location Address
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Address Line | 2950 W CHICAGO AVE SUITE 202
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City | CHICAGO
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State | IL
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Zip | 60622-4375
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Country | US
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Telephone | 618-444-8801
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Fax |
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Provider Business Mailing Address
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Address Line | 2950 W CHICAGO AVE SUITE 202
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City | CHICAGO
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State | IL
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Zip | 60622-4375
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Country | US
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Telephone | 618-444-8801
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Fax |
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Authorized Official
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Title or Position | BILLING DIRECTOR, STAFF THERAPIST
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Name | MRS. AMANDA G BULL
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Credential | MA, LCPC
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Telephone | 618-444-8801
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 103TC0700X
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Taxonomy Name | Clinical Psychologist
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License Number | 071.008116
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License Number State | IL
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Taxonomy #2
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Taxonomy Code | 101YP2500X
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Taxonomy Name | Professional Counselor
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License Number | 180008030
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License Number State | IL
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