=====================================================
General NPI Number Information
=====================================================
NPI Number | 1013652361
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | EMPOWERING TO ELEVATE INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/02/2022
-----------------------------------------------------
Last Update Date | 07/29/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 31 S MAIN ST
-----------------------------------------------------
City | DAYTON
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 45402-2070
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 937-248-1264
-----------------------------------------------------
Fax | 937-315-6121
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 31 S MAIN ST STE 240
-----------------------------------------------------
City | DAYTON
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 45402-2070
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 937-248-1264
-----------------------------------------------------
Fax | 937-315-6121
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CEO
-----------------------------------------------------
Name | ZACHARY LOGAN
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 937-248-1264
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QM0855X
-----------------------------------------------------
Taxonomy Name | Adolescent and Children Mental Health Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------