Healthcare Provider Details

I. General information

NPI: 1033700703
Provider Name (Legal Business Name): AWAKEN THE GREATNESS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/26/2021
Last Update Date: 01/26/2021
Certification Date: 01/26/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1822 S 39TH ST UNIT 120
MESA AZ
85206-3831
US

IV. Provider business mailing address

2007 S LAS PALMAS
MESA AZ
85202-6352
US

V. Phone/Fax

Practice location:
  • Phone: 424-219-0315
  • Fax:
Mailing address:
  • Phone: 424-219-0315
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State

VIII. Authorized Official

Name: CHERISE JOY THOMAS
Title or Position: OWNER
Credential: MS
Phone: 424-219-0315