Healthcare Provider Details

I. General information

NPI: 1831885359
Provider Name (Legal Business Name): WILD EMPOWERMENT LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/17/2023
Last Update Date: 10/07/2026
Certification Date: 10/07/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

45 FAIR ST
WALLINGFORD CT
06492-4208
US

IV. Provider business mailing address

45 FAIR ST FL 1
WALLINGFORD CT
06492-4208
US

V. Phone/Fax

Practice location:
  • Phone: 203-951-1393
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number StateNULL

VIII. Authorized Official

Name: GINA AMANTE
Title or Position: OWNER / CLINICIAN
Credential: LCSW
Phone: 203-951-1393