Healthcare Provider Details

I. General information

NPI: 1114041332
Provider Name (Legal Business Name): EMPOWERMENT THROUGH ADVENTURE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/16/2007
Last Update Date: 04/23/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

86 ELGIN AVENUE
WESTMONT NJ
08108
US

IV. Provider business mailing address

86 ELGIN AVENUE
WESTMONT NJ
08108
US

V. Phone/Fax

Practice location:
  • Phone: 609-828-2110
  • Fax: 856-854-5423
Mailing address:
  • Phone: 609-828-2110
  • Fax: 856-869-2830

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number44SC05230400
License Number StateNJ

VIII. Authorized Official

Name: MS. JENNIFER K WIRTH
Title or Position: OWNER
Credential: LCSW
Phone: 609-828-2110