=====================================================
General NPI Number Information
=====================================================
NPI Number | 1366073546
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | AWAKENED LIFE HEALING, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/28/2020
-----------------------------------------------------
Last Update Date | 01/28/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 10801 BIG BEND RD
-----------------------------------------------------
City | KIRKWOOD
-----------------------------------------------------
State | MO
-----------------------------------------------------
Zip | 63122-6055
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 314-467-0441
-----------------------------------------------------
Fax | 314-677-3512
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 597 SUMMIT VIEW DR
-----------------------------------------------------
City | FENTON
-----------------------------------------------------
State | MO
-----------------------------------------------------
Zip | 63026-3847
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 314-640-5846
-----------------------------------------------------
Fax | 314-677-3512
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | SARAH BUEHNER
-----------------------------------------------------
Credential | LCSW
-----------------------------------------------------
Telephone | 410-303-8946
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QM0801X
-----------------------------------------------------
Taxonomy Name | Mental Health Clinic/Center (Including Community Mental Health Center)
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------