Healthcare Provider Details

I. General information

NPI: 1669029708
Provider Name (Legal Business Name): AWAKEN FREEDOM, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/22/2019
Last Update Date: 07/24/2020
Certification Date: 07/24/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

581 W 17TH AVE
EUGENE OR
97401-3816
US

IV. Provider business mailing address

581 W 17TH AVE
EUGENE OR
97401-3816
US

V. Phone/Fax

Practice location:
  • Phone: 541-204-2462
  • Fax:
Mailing address:
  • Phone: 541-204-2462
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier500668772
Identifier TypeMEDICAID
Identifier StateOR
Identifier Issuer

VIII. Authorized Official

Name: REBECCA SUZANNE PERDEW
Title or Position: OWNER
Credential: LCSW
Phone: 541-204-2462