Provider Demographics
NPI:1962947101
Name:AWAKENING BEHAVIORAL HEALTH, LLC
Entity type:Organization
Organization Name:AWAKENING BEHAVIORAL HEALTH, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CCO, EXEC DIR PAYOR RELATIONS
Authorized Official - Prefix:
Authorized Official - First Name:KERRYLYNN
Authorized Official - Middle Name:
Authorized Official - Last Name:BACA-PELPHREY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:801-658-9646
Mailing Address - Street 1:2973 W 13800 S
Mailing Address - Street 2:
Mailing Address - City:BLUFFDALE
Mailing Address - State:UT
Mailing Address - Zip Code:84065
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:9160 S 300 W STE 3
Practice Address - Street 2:
Practice Address - City:SANDY
Practice Address - State:UT
Practice Address - Zip Code:84070-2656
Practice Address - Country:US
Practice Address - Phone:801-545-0406
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:AWAKENING BEHAVIORAL HEALTH, LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2016-12-26
Last Update Date:2023-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT37088261QM0850X
UT37087261QR0405X
261QR0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0800XAmbulatory Health Care FacilitiesClinic/CenterRecovery Care
No261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health
No261QR0405XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation, Substance Use Disorder
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT54650OtherSTATE OF UTAH HUMAN SERVICES