Provider Demographics
NPI:1093079212
Name:AGAVE STUDIO FOR PSYCHOTHERAPY AND SPIRITUAL DIRECTION
Entity Type:Organization
Organization Name:AGAVE STUDIO FOR PSYCHOTHERAPY AND SPIRITUAL DIRECTION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR AND FOUNDER
Authorized Official - Prefix:DR
Authorized Official - First Name:JANEIL
Authorized Official - Middle Name:IRENE
Authorized Official - Last Name:RUIZ
Authorized Official - Suffix:
Authorized Official - Credentials:PSYD
Authorized Official - Phone:773-627-2112
Mailing Address - Street 1:1333 N ARTESIAN AVE # 2
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60622-2935
Mailing Address - Country:US
Mailing Address - Phone:773-627-2112
Mailing Address - Fax:
Practice Address - Street 1:2950 W CHICAGO AVE
Practice Address - Street 2:#302
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60622-4375
Practice Address - Country:US
Practice Address - Phone:773-627-2112
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-07-02
Last Update Date:2012-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101Y00000X, 101YP1600X
IL071.008116103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Multi-Specialty
No101Y00000XBehavioral Health & Social Service ProvidersCounselorGroup - Multi-Specialty
No101YP1600XBehavioral Health & Social Service ProvidersCounselorPastoralGroup - Multi-Specialty