Healthcare Provider Details

I. General information

NPI: 1710702204
Provider Name (Legal Business Name): EMPOWERED LEGACY CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/19/2024
Last Update Date: 12/06/2024
Certification Date: 12/06/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1200 HARTFORD AVE STE 3B
JOHNSTON RI
02919-7143
US

IV. Provider business mailing address

1200 HARTFORD AVE STE 3B
JOHNSTON RI
02919-7143
US

V. Phone/Fax

Practice location:
  • Phone: 401-263-0778
  • Fax:
Mailing address:
  • Phone: 401-263-0778
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number State

VIII. Authorized Official

Name: FRANK LUDERS PAUL
Title or Position: THERAPIST
Credential: LICSW
Phone: 401-263-0778