| Agave Studio, Llc | |
|
2950 W Chicago Ave Suite 202 Chicago IL 60622-4375 | |
| (618) 444-8801 | |
| Not Available |
| Full Name | Agave Studio, Llc |
|---|---|
| Speciality | Counselor - Professional |
| Location | 2950 W Chicago Ave, Chicago, Illinois |
| Authorized Official Name and Position | Amanda G Bull (BILLING DIRECTOR, STAFF THERAPIST) |
| Authorized Official Contact | 6184448801 |
| Accepts Medicare Insurance | This clinic does not participate in Medicare Program. |
| Mailing Address | Practice Location Address |
|---|---|
| Agave Studio, Llc 2950 W Chicago Ave Suite 202 Chicago IL 60622-4375 Ph: (618) 444-8801 | Agave Studio, Llc 2950 W Chicago Ave Suite 202 Chicago IL 60622-4375 Ph: (618) 444-8801 |
| NPI Number | 1023427861 |
|---|---|
| Provider Enumeration Date | 08/06/2014 |
| Last Update Date | 08/12/2014 |
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 1023427861 | NPI | - | NPPES |
| Taxonomy | Type | License (State) | Status |
|---|---|---|---|
| 101YP2500X | Counselor - Professional | 180008030 (Illinois) | Primary |
| 103TC0700X | Psychologist - Clinical | 071.008116 (Illinois) | Secondary |
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