Basic Information
| Provider Information | |||||||||
| NPI: | 1811173792 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | THE AWARENESS PROGRAM | ||||||||
| LastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 45550 GRACE ST | ||||||||
| Address2: | |||||||||
| City: | INDIO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 922014610 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7603421233 | ||||||||
| FaxNumber: | 7603425344 | ||||||||
| Practice Location | |||||||||
| Address1: | 45550 GRACE ST | ||||||||
| Address2: | |||||||||
| City: | INDIO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 922014610 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7603421233 | ||||||||
| FaxNumber: | 7603425344 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/10/2008 | ||||||||
| LastUpdateDate: | 01/10/2008 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | BIBBY | ||||||||
| AuthorizedOfficialFirstName: | CANDACE | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | ADMINISTRATOR | ||||||||
| AuthorizedOfficialTelephone: | 7603421233 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MS. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YA0400X | 3300101120 | CA | Y | 193400000X SINGLE SPECIALTY GROUP | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) |
No ID Information.