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General NPI Number Information
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NPI Number | 1447786652
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Entity Type | Organization
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Legal Business Name | AWAKENING GROWTH, LLC
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Dates
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Enumeration Date | 05/08/2017
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Last Update Date | 05/08/2017
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Provider Practice Location Address
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Address Line | 116 AVE C
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City | CLOQUET
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State | MN
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Zip | 55720
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Country | US
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Telephone | 218-591-0068
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Fax |
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Provider Business Mailing Address
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Address Line | 116 AVE C
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City | CLOQUET
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State | MN
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Zip | 55720
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Country | US
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Telephone | 218-591-0068
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | AMANDA RADTKE
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Credential | MSW, LICSW
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Telephone | 218-591-0068
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1041C0700X
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Taxonomy Name | Clinical Social Worker
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License Number | 22551
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License Number State | MN
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