Provider Demographics
NPI:1952117533
Name:AWAKEN BY WELLNESS LLC
Entity type:Organization
Organization Name:AWAKEN BY WELLNESS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTITIONER
Authorized Official - Prefix:
Authorized Official - First Name:AGA
Authorized Official - Middle Name:DANEEN
Authorized Official - Last Name:YOUNG
Authorized Official - Suffix:
Authorized Official - Credentials:LIFESTYLE/WELLNESS
Authorized Official - Phone:228-213-7972
Mailing Address - Street 1:606 NORTH UTICA STREET
Mailing Address - Street 2:
Mailing Address - City:TERRY
Mailing Address - State:MS
Mailing Address - Zip Code:39170
Mailing Address - Country:US
Mailing Address - Phone:228-213-7972
Mailing Address - Fax:
Practice Address - Street 1:606 NORTH UTICA STREET
Practice Address - Street 2:
Practice Address - City:TERRY
Practice Address - State:MS
Practice Address - Zip Code:39170
Practice Address - Country:US
Practice Address - Phone:228-213-7972
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-12-09
Last Update Date:2024-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QC1500XAmbulatory Health Care FacilitiesClinic/CenterCommunity Health
No251300000XAgenciesLocal Education Agency (LEA)
No251B00000XAgenciesCase Management
No251T00000XAgenciesProgram of All-Inclusive Care for the Elderly (PACE) Provider Organization
No305R00000XManaged Care OrganizationsPreferred Provider Organization
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS1790491355Medicaid