Provider Demographics
NPI:1124492665
Name:AWAKEN THE SPIRIT LLC
Entity type:Organization
Organization Name:AWAKEN THE SPIRIT LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:MANAGING DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:CHERYL
Authorized Official - Middle Name:A
Authorized Official - Last Name:DEPETRO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:410-747-9743
Mailing Address - Street 1:9 NEWBURG AVE STE 100
Mailing Address - Street 2:
Mailing Address - City:CATONSVILLE
Mailing Address - State:MD
Mailing Address - Zip Code:21228-5168
Mailing Address - Country:US
Mailing Address - Phone:410-747-9743
Mailing Address - Fax:410-747-9910
Practice Address - Street 1:9 NEWBURG AVE STE 100
Practice Address - Street 2:
Practice Address - City:CATONSVILLE
Practice Address - State:MD
Practice Address - Zip Code:21228-5168
Practice Address - Country:US
Practice Address - Phone:410-747-9743
Practice Address - Fax:410-747-9910
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-11-20
Last Update Date:2024-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDU01507171100000X
MD091771041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty
No171100000XOther Service ProvidersAcupuncturistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD149702200Medicaid
MD929ROtherMEDICARE