1104606011 NPI number — AGUAYO THERAPEUTIC SERVICES LLC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1104606011 NPI number — AGUAYO THERAPEUTIC SERVICES LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
AGUAYO THERAPEUTIC SERVICES LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
ELIZABETH AGUAYO LCSW
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1104606011
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/24/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
436 SPRING CANYON DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
HEBRON
Provider Business Mailing Address State Name:
IN
Provider Business Mailing Address Postal Code:
46341-8627
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
219-433-3741
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
119 BROADWAY STE 108
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CHESTERTON
Provider Business Practice Location Address State Name:
IN
Provider Business Practice Location Address Postal Code:
46304-2477
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
219-281-2276
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
09/29/2023

Additional Information

Authorized Official

Authorized Official Last Name:
AGUAYO
Authorized Official First Name:
ELIZABETH
Authorized Official Middle Name:
ANN
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
219-281-2276

Provider Taxonomy Codes

  • Taxonomy code: 1041C0700X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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