MEDICARE: A-AGELOPOULOS, 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	071007911	IL

General Provider Information

NPI Number	:	1295034841
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	A-AGELOPOULOS, LLC

Provider Business Mailing Address
First Line	:	1638 W AUGUSTA BLVD
Second Line	:	UNIT 2
City	:	CHICAGO
State	:	IL
Zip	:	60622-3806
Country	:	US
Telephone Number	:	773-992-8024
Fax Number	:

Provider Business Practice Location Address
First Line	:	222 MERCHANDISE MART PLZ
Second Line	:	SUITE 4111
City	:	CHICAGO
State	:	IL
Zip	:	60654-1103
Country	:	US
Telephone Number	:	773-992-8024
Fax Number	:

Authorized Official
Title or Position	:	LICENSED CLINICAL PSYCHOLOGIST
Name	:	DR. ANGELA E AGELOPOULOS
Credential	:	PSY.D.
Telephone Number	:	773-992-8024

Provider Enumeration Date	:	03/22/2011
Last Update Date	:	03/22/2011

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