Provider Demographics
NPI:1285086769
Name:EARTH SPIRIT AWAKENINGS
Entity type:Organization
Organization Name:EARTH SPIRIT AWAKENINGS
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:TOD
Authorized Official - Middle Name:
Authorized Official - Last Name:DICECCO
Authorized Official - Suffix:
Authorized Official - Credentials:LPCC
Authorized Official - Phone:505-983-8225
Mailing Address - Street 1:2019 GALISTEO ST
Mailing Address - Street 2:
Mailing Address - City:SANTA FE
Mailing Address - State:NM
Mailing Address - Zip Code:87505-2143
Mailing Address - Country:US
Mailing Address - Phone:505-983-8225
Mailing Address - Fax:505-930-5427
Practice Address - Street 1:2019 GALISTEO ST
Practice Address - Street 2:
Practice Address - City:SANTA FE
Practice Address - State:NM
Practice Address - Zip Code:87505-2143
Practice Address - Country:US
Practice Address - Phone:505-983-8225
Practice Address - Fax:505-930-5427
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-07-07
Last Update Date:2016-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM1600129265101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty