=====================================================
General NPI Number Information
=====================================================
NPI Number | 1396447132
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | AWAKE IN WELLNESS MUSIC THERAPY, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/17/2023
-----------------------------------------------------
Last Update Date | 03/17/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1430 NELSON RD STE 221
-----------------------------------------------------
City | LONGMONT
-----------------------------------------------------
State | CO
-----------------------------------------------------
Zip | 80501-6399
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 303-349-8918
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4010 W 4TH ST
-----------------------------------------------------
City | GREELEY
-----------------------------------------------------
State | CO
-----------------------------------------------------
Zip | 80634-1135
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 303-349-8918
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OPERATING MANAGER
-----------------------------------------------------
Name | JESSICA M DITTY
-----------------------------------------------------
Credential | MT-BC
-----------------------------------------------------
Telephone | 303-349-8918
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225A00000X
-----------------------------------------------------
Taxonomy Name | Music Therapist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------