Provider Demographics
NPI:1073979530
Name:WI AWAKEN LLC
Entity Type:Organization
Organization Name:WI AWAKEN LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:THERAPIST
Authorized Official - Prefix:
Authorized Official - First Name:STEPHANIE
Authorized Official - Middle Name:
Authorized Official - Last Name:COATES
Authorized Official - Suffix:
Authorized Official - Credentials:MS, LPC, SAC
Authorized Official - Phone:262-379-0942
Mailing Address - Street 1:PO BOX 189
Mailing Address - Street 2:
Mailing Address - City:BURLINGTON
Mailing Address - State:WI
Mailing Address - Zip Code:53105-0189
Mailing Address - Country:US
Mailing Address - Phone:262-342-5188
Mailing Address - Fax:
Practice Address - Street 1:157 S PINE ST
Practice Address - Street 2:
Practice Address - City:BURLINGTON
Practice Address - State:WI
Practice Address - Zip Code:53105-1911
Practice Address - Country:US
Practice Address - Phone:262-342-5188
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-01-13
Last Update Date:2016-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)