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General NPI Number Information
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NPI Number | 1780403501
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Entity Type | Organization
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Legal Business Name | AGAVE MEDICAL NY, P.C
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Dates
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Enumeration Date | 10/08/2024
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Last Update Date | 03/13/2025
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Provider Practice Location Address
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Address Line | 16397 ROAD 37
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City | MADERA
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State | CA
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Zip | 93636-8224
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Country | US
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Telephone | 510-871-5025
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Fax |
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Provider Business Mailing Address
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Address Line | 359 5TH ST UNIT 3
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City | JERSEY CITY
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State | NJ
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Zip | 07302-2329
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position | CEO
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Name | MICHAEL SCAHILL
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Credential |
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Telephone | 510-871-5025
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 101YM0800X
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Taxonomy Name | Mental Health Counselor
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 103TH0004X
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Taxonomy Name | Health Psychologist
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License Number |
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License Number State |
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Taxonomy #3
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Taxonomy Code | 104100000X
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Taxonomy Name | Social Worker
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License Number |
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License Number State |
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Taxonomy #4
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Taxonomy Code | 103T00000X
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Taxonomy Name | Psychologist
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License Number |
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License Number State |
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