=====================================================
General NPI Number Information
=====================================================
NPI Number | 1053059733
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | AWARENESS BEHAVIORAL HEALTH, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/23/2022
-----------------------------------------------------
Last Update Date | 04/28/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 11005 PEARL RD STE 3
-----------------------------------------------------
City | STRONGSVILLE
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 44136-3352
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 440-694-5652
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 27061 GLENSIDE LN
-----------------------------------------------------
City | OLMSTED TWP
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 44138-3170
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 440-694-5652
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | BILLER
-----------------------------------------------------
Name | AMY WAGNER
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 215-964-0335
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------