Healthcare Provider Details

I. General information

NPI: 1457022808
Provider Name (Legal Business Name): ESSENTIALLY EMPOWERED, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/24/2021
Last Update Date: 09/28/2021
Certification Date: 09/28/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2715 W CARMEN AVE
MILWAUKEE WI
53209-4228
US

IV. Provider business mailing address

2715 W CARMEN AVE
MILWAUKEE WI
53209-4228
US

V. Phone/Fax

Practice location:
  • Phone: 262-505-7811
  • Fax:
Mailing address:
  • Phone: 262-505-7811
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code172V00000X
TaxonomyCommunity Health Worker
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number StateNULL
# 3
Primary TaxonomyN
Taxonomy Code374J00000X
TaxonomyDoula
License Number
License Number StateNULL

VIII. Authorized Official

Name: MRS. LAKEETA WATTS
Title or Position: EXECUTIVE DIRECTOR
Credential: CHW, CLS, DOUA
Phone: 262-505-7811