Healthcare Provider Details

I. General information

NPI: 1629747142
Provider Name (Legal Business Name): LOST DREAMS AWAKEN
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/08/2021
Last Update Date: 04/21/2023
Certification Date: 04/21/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

823 E ORANGEBURG AVE
MODESTO CA
95350-4619
US

IV. Provider business mailing address

823 E ORANGEBURG AVE
MODESTO CA
95350-4619
US

V. Phone/Fax

Practice location:
  • Phone: 209-527-9797
  • Fax: 209-527-9825
Mailing address:
  • Phone: 209-527-9797
  • Fax: 209-527-9825

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code324500000X
TaxonomySubstance Abuse Rehabilitation Facility
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number StateNULL

VIII. Authorized Official

Name: MS. CATHY ROBISON
Title or Position: MANAGING PARTNER
Credential: SUDCC II
Phone: 209-527-9797