Healthcare Provider Details

I. General information

NPI: 1952117533
Provider Name (Legal Business Name): AWAKEN BY WELLNESS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/09/2024
Last Update Date: 12/09/2024
Certification Date: 12/08/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

606 NORTH UTICA STREET
TERRY MS
39170
US

IV. Provider business mailing address

606 NORTH UTICA STREET
TERRY MS
39170
US

V. Phone/Fax

Practice location:
  • Phone: 228-213-7972
  • Fax:
Mailing address:
  • Phone: 228-213-7972
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code251300000X
TaxonomyLocal Education Agency (LEA)
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code251B00000X
TaxonomyCase Management Agency
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code251T00000X
TaxonomyPACE Provider Organization
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code305R00000X
TaxonomyPreferred Provider Organization
License Number
License Number State
# 5
Primary TaxonomyY
Taxonomy Code261QC1500X
TaxonomyCommunity Health Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: AGA DANEEN YOUNG
Title or Position: PRACTITIONER
Credential: LIFESTYLE/WELLNESS
Phone: 228-213-7972