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NPI Code Detail

MEDICARE: IMTISAL AWAN

MEDICARE: IMTISAL AWAN
Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

# Taxonomy Code Taxonomy License Number License Number State
1106S00000XBehavior Technician

General Provider Information

NPI Number : 1215860952
Entity Type Code : Individual
Provider Name (Legal Business Name) : IMTISAL AWAN
Provider Business Mailing Address
First Line : 3415 BATAAN MEMORIAL W
Second Line :
City : LAS CRUCES
State : NM
Zip : 88012-5012
Country : US
Telephone Number : 505-392-3482
Fax Number :
Provider Business Practice Location Address
First Line : 325 1ST AVE
Second Line :
City : BAYPORT
State : NY
Zip : 11705-1303
Country : US
Telephone Number : 631-889-5185
Fax Number :
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 06/03/2026
Last Update Date : 06/03/2026

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Directions to “ IMTISAL AWAN ” Practice Location

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