Healthcare Provider Details

I. General information

NPI: 1174097547
Provider Name (Legal Business Name): AWAKEN LICENSED APPLIED BEHAVIORAL ANALYSIS SERVICES PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/18/2019
Last Update Date: 04/30/2021
Certification Date: 04/30/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8480 BALTIMORE NATIONAL PIKE STE 3210 #126
ELLICOTT CITY MD
21043
US

IV. Provider business mailing address

8480 BALTIMORE NATIONAL PIKE STE 3210 #126
ELLICOTT CITY MD
21043
US

V. Phone/Fax

Practice location:
  • Phone: 914-713-7974
  • Fax:
Mailing address:
  • Phone: 914-713-7974
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State

VIII. Authorized Official

Name: MRS. PETAGAYE S. TOWNSEND
Title or Position: CHIEF OPERATING OFFICER
Credential: MS, BCBA, LBA
Phone: 914-363-8313