=====================================================
General NPI Number Information
=====================================================
NPI Number | 1134955198
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | AWAKEN WELLNESS WITHIN
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/09/2024
-----------------------------------------------------
Last Update Date | 10/22/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1425 POMPTON AVE STE 1-3
-----------------------------------------------------
City | CEDAR GROVE
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 07009-1043
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 909-220-9743
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 46 HARRISON AVE
-----------------------------------------------------
City | ROSELAND
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 07068-1256
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 862-754-2723
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | JESSICA LYNN ALCIUS
-----------------------------------------------------
Credential | LCSW
-----------------------------------------------------
Telephone | 862-754-2723
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QM0850X
-----------------------------------------------------
Taxonomy Name | Adult Mental Health Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 261QM0855X
-----------------------------------------------------
Taxonomy Name | Adolescent and Children Mental Health Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 261QM0801X
-----------------------------------------------------
Taxonomy Name | Mental Health Clinic/Center (Including Community Mental Health Center)
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------