MEDICARE: AGAVE STUDIO, LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	103TC0700X	Clinical Psychologist	071.008116	IL
2	101YP2500X	Professional Counselor	180008030	IL

General Provider Information

NPI Number	:	1023427861
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	AGAVE STUDIO, LLC

Provider Business Mailing Address
First Line	:	2950 W CHICAGO AVE
Second Line	:	SUITE 202
City	:	CHICAGO
State	:	IL
Zip	:	60622-4375
Country	:	US
Telephone Number	:	618-444-8801
Fax Number	:

Provider Business Practice Location Address
First Line	:	2950 W CHICAGO AVE
Second Line	:	SUITE 202
City	:	CHICAGO
State	:	IL
Zip	:	60622-4375
Country	:	US
Telephone Number	:	618-444-8801
Fax Number	:

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

Provider Enumeration Date	:	08/06/2014
Last Update Date	:	08/12/2014

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