MEDICARE: AGAVE STUDIO FOR PSYCHOTHERAPY AND SPIRITUAL DIRECTION

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	101Y00000X	Counselor
2	101YP1600X	Pastoral Counselor
3	103TC0700X	Clinical Psychologist	071.008116	IL

General Provider Information

NPI Number	:	1093079212
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	AGAVE STUDIO FOR PSYCHOTHERAPY AND SPIRITUAL DIRECTION

Provider Business Mailing Address
First Line	:	1333 N ARTESIAN AVE # 2
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60622-2935
Country	:	US
Telephone Number	:	773-627-2112
Fax Number	:

Provider Business Practice Location Address
First Line	:	2950 W CHICAGO AVE
Second Line	:	#302
City	:	CHICAGO
State	:	IL
Zip	:	60622-4375
Country	:	US
Telephone Number	:	773-627-2112
Fax Number	:

Authorized Official
Title or Position	:	EXECUTIVE DIRECTOR AND FOUNDER
Name	:	DR. JANEIL IRENE RUIZ
Credential	:	PSY.D.
Telephone Number	:	773-627-2112

Provider Enumeration Date	:	07/02/2012
Last Update Date	:	07/02/2012

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