Healthcare Provider Details

I. General information

NPI: 1275102691
Provider Name (Legal Business Name): EMPOWERING MINDS 4 CHANGE, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/21/2021
Last Update Date: 09/14/2023
Certification Date: 09/14/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4301 STRETTON FARM CT
WOODBRIDGE VA
22192-5564
US

IV. Provider business mailing address

4301 STRETTON FARM CT
WOODBRIDGE VA
22192-5564
US

V. Phone/Fax

Practice location:
  • Phone: 571-580-9160
  • Fax:
Mailing address:
  • Phone: 571-580-9160
  • 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 Code103TC0700X
TaxonomyClinical Psychologist
License Number
License Number State

VIII. Authorized Official

Name: JENNIFER CLEMENTS
Title or Position: BOARD CERTIFIED BEHAVIOR ANALYST
Credential: BCBA, LBA TLLP
Phone: 248-704-4751