Provider Demographics
NPI:1659084630
Name:MENTAL AWAKENING COUNSELING, LLC
Entity Type:Organization
Organization Name:MENTAL AWAKENING COUNSELING, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER AND PROVIDER
Authorized Official - Prefix:
Authorized Official - First Name:ROBIN
Authorized Official - Middle Name:LYNN
Authorized Official - Last Name:JORDAN
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:502-689-1613
Mailing Address - Street 1:2950 BRECKENRIDGE LN STE 10A
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40220-1495
Mailing Address - Country:US
Mailing Address - Phone:502-689-1613
Mailing Address - Fax:502-242-0086
Practice Address - Street 1:2950 BRECKENRIDGE LN STE 10A
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40220-1495
Practice Address - Country:US
Practice Address - Phone:502-689-1613
Practice Address - Fax:502-242-0086
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-01-04
Last Update Date:2023-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty