Healthcare Provider Details

I. General information

NPI: 1649947607
Provider Name (Legal Business Name): AWA PEDIATRIC BEHAVIORAL SERVICES LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/26/2021
Last Update Date: 04/25/2022
Certification Date: 04/25/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1188 FORESTGLEN DR APT E
BOZEMAN MT
59718-6693
US

IV. Provider business mailing address

1188 FORESTGLEN DR APT E
BOZEMAN MT
59718-6693
US

V. Phone/Fax

Practice location:
  • Phone: 602-999-8824
  • Fax:
Mailing address:
  • Phone: 602-999-8824
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code253Z00000X
TaxonomyIn Home Supportive Care Agency
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code3747A0650X
TaxonomyAttendant Care Provider
License Number
License Number State

VIII. Authorized Official

Name: BRYTNE E SKOCYPIEC
Title or Position: OWNER
Credential:
Phone: 406-224-3130