Organization
AGAVE STUDIO, LLC
Active
Organization subpart
No
Provider details
NPI number
Authorized official
MRS. AMANDA G BULL MA, LCPC (BILLING DIRECTOR, STAFF THERAPIST)
(618) 444-8801
Entity
Organization
Contact information
Practice address
2950 W CHICAGO AVE, SUITE 202, CHICAGO, IL 60622-4375
(618) 444-8801
Mailing address
2950 W CHICAGO AVE, SUITE 202, CHICAGO, IL 60622-4375
(618) 444-8801
Taxonomy
Speciality
Code
Description
License number
State
101YP2500X
Professional Counselor
Primary
180008030
IL
103TC0700X
Clinical Psychologist
071.008116
IL
Other
Enumeration date
08/06/2014
Last updated
08/12/2014
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