=====================================================
General NPI Number Information
=====================================================
NPI Number | 1750450755
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | AWAKEN TO CHANGE, P.C.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/06/2006
-----------------------------------------------------
Last Update Date | 07/26/2009
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 950 OFFICE PARK RD STE 200B
-----------------------------------------------------
City | WEST DES MOINES
-----------------------------------------------------
State | IA
-----------------------------------------------------
Zip | 50265-2549
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 515-244-7007
-----------------------------------------------------
Fax | 515-244-3238
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 950 OFFICE PARK RD STE 200B
-----------------------------------------------------
City | WEST DES MOINES
-----------------------------------------------------
State | IA
-----------------------------------------------------
Zip | 50265-2549
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 515-244-7007
-----------------------------------------------------
Fax | 515-244-3238
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PSYCHOLOGIST
-----------------------------------------------------
Name | DR. SANDRA L. DAVIS
-----------------------------------------------------
Credential | PH.D.
-----------------------------------------------------
Telephone | 515-244-7007
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 103T00000X
-----------------------------------------------------
Taxonomy Name | Psychologist
-----------------------------------------------------
License Number | 00263
-----------------------------------------------------
License Number State | IA
-----------------------------------------------------