=====================================================
General NPI Number Information
=====================================================
NPI Number | 1275052599
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | AWAKEN GRACE LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/18/2017
-----------------------------------------------------
Last Update Date | 09/17/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 13975 MANCHESTER RD STE 2 ROOM # 17
-----------------------------------------------------
City | MANCHESTER
-----------------------------------------------------
State | MO
-----------------------------------------------------
Zip | 63011-4500
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 314-578-3551
-----------------------------------------------------
Fax | 855-744-8767
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1347 CULPEPPER RIDGE DR
-----------------------------------------------------
City | BALLWIN
-----------------------------------------------------
State | MO
-----------------------------------------------------
Zip | 63021-7526
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 314-578-3551
-----------------------------------------------------
Fax | 855-744-8767
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MANAGER/ SOLE PROPRIETOR
-----------------------------------------------------
Name | ALLISON A GRACE
-----------------------------------------------------
Credential | LCSW
-----------------------------------------------------
Telephone | 314-578-3551
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number | 003113
-----------------------------------------------------
License Number State | MO
-----------------------------------------------------