Healthcare Provider Details

I. General information

NPI: 1164270633
Provider Name (Legal Business Name): EMPOWERED HEALING LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/09/2024
Last Update Date: 05/09/2024
Certification Date: 05/09/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3140 SHERIDAN DR STE 209
AMHERST NY
14226-1913
US

IV. Provider business mailing address

244 SOMERVILLE AVE
TONAWANDA NY
14150-8708
US

V. Phone/Fax

Practice location:
  • Phone: 716-545-5421
  • Fax: 716-262-3953
Mailing address:
  • Phone: 716-940-0079
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name: COURTNEY LYNN POLKA
Title or Position: OWNER
Credential: LCSW CCTP ADHD-CCSP
Phone: 716-545-4324