Provider Demographics
NPI:1245502053
Name:GLORIA AWEKE
Entity type:Organization
Organization Name:GLORIA AWEKE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:RN
Authorized Official - Prefix:
Authorized Official - First Name:GLORIA
Authorized Official - Middle Name:
Authorized Official - Last Name:AWEKE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:608-834-1473
Mailing Address - Street 1:1111 GAS LIGHT DR
Mailing Address - Street 2:
Mailing Address - City:SUN PRAIRIE
Mailing Address - State:WI
Mailing Address - Zip Code:53590-3459
Mailing Address - Country:US
Mailing Address - Phone:608-834-1473
Mailing Address - Fax:
Practice Address - Street 1:1111 GAS LIGHT DR
Practice Address - Street 2:
Practice Address - City:SUN PRAIRIE
Practice Address - State:WI
Practice Address - Zip Code:53590-3459
Practice Address - Country:US
Practice Address - Phone:608-834-1473
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-02-08
Last Update Date:2012-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI167973-30320600000X, 320700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320700000XResidential Treatment FacilitiesResidential Treatment Facility, Physical Disabilities
No320600000XResidential Treatment FacilitiesResidential Treatment Facility, Intellectual and/or Developmental Disabilities