=====================================================
General NPI Number Information
=====================================================
NPI Number | 1194470336
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | AEG WELLNESS
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/16/2022
-----------------------------------------------------
Last Update Date | 02/16/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1020 MILWAUKEE AVE
-----------------------------------------------------
City | DEERFIELD
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60015-3513
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 847-807-8740
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 529 SUSAN LN
-----------------------------------------------------
City | DEERFIELD
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60015-3950
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 847-533-0955
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | LCSW, OWNER
-----------------------------------------------------
Name | ABBY E GAGERMAN
-----------------------------------------------------
Credential | LCSW
-----------------------------------------------------
Telephone | 847-807-8740
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 251S00000X
-----------------------------------------------------
Taxonomy Name | Community/Behavioral Health Agency
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------