Healthcare Provider Details

I. General information

NPI: 1518568351
Provider Name (Legal Business Name): SHAPE EMPOWER CHANGE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/06/2020
Last Update Date: 11/06/2020
Certification Date: 11/06/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

104 KRONOS LN
CARY NC
27513-5339
US

IV. Provider business mailing address

104 KRONOS LN
CARY NC
27513-5339
US

V. Phone/Fax

Practice location:
  • Phone: 203-980-1534
  • Fax:
Mailing address:
  • Phone: 203-980-1534
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code252Y00000X
TaxonomyEarly Intervention Provider Agency
License Number
License Number State

VIII. Authorized Official

Name: SARA CARBONE
Title or Position: FOUNDER
Credential: BCBA
Phone: 203-980-1534