Healthcare Provider Details

I. General information

NPI: 1629896725
Provider Name (Legal Business Name): EMPOWERED THERAPY GROUP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/28/2024
Last Update Date: 09/28/2024
Certification Date: 09/28/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4411 CARMELO ST
SAN DIEGO CA
92107-4211
US

IV. Provider business mailing address

4411 CARMELO ST
SAN DIEGO CA
92107-4211
US

V. Phone/Fax

Practice location:
  • Phone: 760-525-0710
  • Fax:
Mailing address:
  • Phone: 760-525-0710
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number
License Number StateNULL
# 3
Primary TaxonomyN
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number StateNULL

VIII. Authorized Official

Name: MEGAN PAYNE
Title or Position: OCCUPATIONAL THERAPIST
Credential: OTR/L
Phone: 619-432-5353