Provider Demographics
NPI:1275052599
Name:AWAKEN GRACE LLC
Entity Type:Organization
Organization Name:AWAKEN GRACE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER/ SOLE PROPRIETOR
Authorized Official - Prefix:
Authorized Official - First Name:ALLISON
Authorized Official - Middle Name:A
Authorized Official - Last Name:GRACE
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:314-578-3551
Mailing Address - Street 1:1347 CULPEPPER RIDGE DR
Mailing Address - Street 2:
Mailing Address - City:BALLWIN
Mailing Address - State:MO
Mailing Address - Zip Code:63021-7526
Mailing Address - Country:US
Mailing Address - Phone:314-578-3551
Mailing Address - Fax:855-744-8767
Practice Address - Street 1:36 KIRKHAM INDUSTRIAL DR STE 100
Practice Address - Street 2:
Practice Address - City:WEBSTER GROVES
Practice Address - State:MO
Practice Address - Zip Code:63119-1754
Practice Address - Country:US
Practice Address - Phone:314-578-3551
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-09-18
Last Update Date:2023-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1490188671041C0700X
MO0031131041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO1629451737OtherNPI