Healthcare Provider Details

I. General information

NPI: 1033588207
Provider Name (Legal Business Name): EMPOWERED THROUGH PLAY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/17/2015
Last Update Date: 08/16/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

560 W CANFIELD AVE STE 300
COEUR D ALENE ID
83815-7950
US

IV. Provider business mailing address

560 W CANFIELD AVE STE 300
COEUR D ALENE ID
83815-7950
US

V. Phone/Fax

Practice location:
  • Phone: 208-758-7111
  • Fax:
Mailing address:
  • Phone: 208-758-7111
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number StateID
# 2
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State

VIII. Authorized Official

Name: STACIA CARR PETERSON
Title or Position: OWNER
Credential: LCPC
Phone: 208-758-7111