Healthcare Provider Details

I. General information

NPI: 1568790426
Provider Name (Legal Business Name): AWAKE AND AWARE, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/03/2009
Last Update Date: 12/03/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

201 HERMOSA DR NE
ALBUQUERQUE NM
87108-1023
US

IV. Provider business mailing address

201 HERMOSA DR NE
ALBUQUERQUE NM
87108-1023
US

V. Phone/Fax

Practice location:
  • Phone: 505-573-0438
  • Fax:
Mailing address:
  • Phone: 505-573-0438
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberI-06756
License Number StateNM

VIII. Authorized Official

Name: MS. NATALIE INEZ SMITH
Title or Position: EXECUTIVE DIRECTOR
Credential: LISW
Phone: 505-573-0438