MEDICARE: AWAKEN THE GREATNESS

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	251S00000X	Community/Behavioral Health Agency
2	101YM0800X	Mental Health Counselor

General Provider Information

NPI Number	:	1033700703
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	AWAKEN THE GREATNESS

Provider Business Mailing Address
First Line	:	2007 S LAS PALMAS
Second Line	:
City	:	MESA
State	:	AZ
Zip	:	85202-6352
Country	:	US
Telephone Number	:	424-219-0315
Fax Number	:

Provider Business Practice Location Address
First Line	:	1822 S 39TH ST UNIT 120
Second Line	:
City	:	MESA
State	:	AZ
Zip	:	85206-3831
Country	:	US
Telephone Number	:	424-219-0315
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	CHERISE JOY THOMAS
Credential	:	MS
Telephone Number	:	424-219-0315

Provider Enumeration Date	:	01/26/2021
Last Update Date	:	01/26/2021

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Directions to “AWAKEN THE GREATNESS ” Practice Location

Language	Start Address	Practice Location

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