Provider Demographics
NPI:1760859680
Name:SELF-AWARENESS, LLC
Entity Type:Organization
Organization Name:SELF-AWARENESS, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ECECUTIVE DIRECTOR/COUNSELOR
Authorized Official - Prefix:MR
Authorized Official - First Name:JEROME
Authorized Official - Middle Name:
Authorized Official - Last Name:MILLER
Authorized Official - Suffix:
Authorized Official - Credentials:CADC
Authorized Official - Phone:515-277-0320
Mailing Address - Street 1:2301 FOREST AVE
Mailing Address - Street 2:
Mailing Address - City:DES MOINES
Mailing Address - State:IA
Mailing Address - Zip Code:50311-3113
Mailing Address - Country:US
Mailing Address - Phone:515-277-0320
Mailing Address - Fax:515-277-0358
Practice Address - Street 1:2301 FOREST AVE
Practice Address - Street 2:
Practice Address - City:DES MOINES
Practice Address - State:IA
Practice Address - Zip Code:50311-3113
Practice Address - Country:US
Practice Address - Phone:515-277-0320
Practice Address - Fax:515-277-0358
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-08-26
Last Update Date:2015-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA1377261QR0405X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0405XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation, Substance Use Disorder
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA601004190OtherMAGELLAN