Healthcare Provider Details

I. General information

NPI: 1922588102
Provider Name (Legal Business Name): AWAKE IN WELLNESS, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/17/2018
Last Update Date: 06/06/2023
Certification Date: 06/06/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1430 NELSON RD STE 221
LONGMONT CO
80501-6399
US

IV. Provider business mailing address

1430 NELSON RD STE 221
LONGMONT CO
80501-6399
US

V. Phone/Fax

Practice location:
  • Phone: 720-340-3869
  • Fax:
Mailing address:
  • Phone: 203-403-8697
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225A00000X
TaxonomyMusic Therapist
License Number11114
License Number StateCO

VIII. Authorized Official

Name: JESSICA MARIE DITTY
Title or Position: OPERATING MANAGER
Credential: MM, MT-BC
Phone: 303-349-8918