Healthcare Provider Details

I. General information

NPI: 1619285046
Provider Name (Legal Business Name): EQUINE AWAKENINGS, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/20/2010
Last Update Date: 04/26/2022
Certification Date: 04/26/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6613B BAY LAUREL PL
AVILA BEACH CA
93424-3504
US

IV. Provider business mailing address

1515 5TH ST
LOS OSOS CA
93402-1611
US

V. Phone/Fax

Practice location:
  • Phone: 561-598-9118
  • Fax:
Mailing address:
  • Phone: 561-598-9118
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberSW9645
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State

VIII. Authorized Official

Name: HOLLY WHALL
Title or Position: OWNER
Credential: LCSW
Phone: 561-598-9118