Healthcare Provider Details

I. General information

NPI: 1205325297
Provider Name (Legal Business Name): INNER AWAKENING THERAPY CENTER LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/04/2018
Last Update Date: 10/04/2021
Certification Date: 10/04/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1575 DETRICK AVE
DELAND FL
32724-2042
US

IV. Provider business mailing address

1575 DETRICK AVE
DELAND FL
32724-2042
US

V. Phone/Fax

Practice location:
  • Phone: 407-906-8633
  • Fax:
Mailing address:
  • Phone: 407-906-8633
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License NumberMH14780
License Number StateFL

VIII. Authorized Official

Name: ADEL M CEBALLOS-ROSARIO
Title or Position: OWNER
Credential: LMHC
Phone: 407-906-8633