Provider Demographics
NPI:1447490800
Name:EARTH SPIRIT AWAKENINGS LLC
Entity type:Organization
Organization Name:EARTH SPIRIT AWAKENINGS LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:TOD
Authorized Official - Middle Name:L
Authorized Official - Last Name:DICECCO
Authorized Official - Suffix:
Authorized Official - Credentials:MA, LPCC
Authorized Official - Phone:505-490-1984
Mailing Address - Street 1:4001 OFFICE COURT DR
Mailing Address - Street 2:SUITE 102
Mailing Address - City:SANTA FE
Mailing Address - State:NM
Mailing Address - Zip Code:87507-4929
Mailing Address - Country:US
Mailing Address - Phone:505-983-8225
Mailing Address - Fax:
Practice Address - Street 1:4001 OFFICE COURT DR STE 102
Practice Address - Street 2:
Practice Address - City:SANTA FE
Practice Address - State:NM
Practice Address - Zip Code:87507-4903
Practice Address - Country:US
Practice Address - Phone:505-983-8225
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-02-25
Last Update Date:2022-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM0119891251S00000X
251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM81024371Medicaid