Provider Demographics
NPI:1639573017
Name:AGEFULLY
Entity Type:Organization
Organization Name:AGEFULLY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:ALIXANDRA
Authorized Official - Middle Name:
Authorized Official - Last Name:FOISY
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:773-939-0556
Mailing Address - Street 1:1022 W 31ST PL APT 1F
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60608-6580
Mailing Address - Country:US
Mailing Address - Phone:773-939-0556
Mailing Address - Fax:
Practice Address - Street 1:1022 W 31ST PL APT 1F
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60608-6580
Practice Address - Country:US
Practice Address - Phone:773-939-0556
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-10-14
Last Update Date:2014-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1490146271041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty