=====================================================
General NPI Number Information
=====================================================
NPI Number | 1083487631
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | EMPOWERED PATHWAYS, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/06/2023
-----------------------------------------------------
Last Update Date | 11/06/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1206 HILLCREST DR
-----------------------------------------------------
City | OCEAN SPRINGS
-----------------------------------------------------
State | MS
-----------------------------------------------------
Zip | 39564-2815
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 228-217-2997
-----------------------------------------------------
Fax | 228-250-1399
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1206 HILLCREST DR
-----------------------------------------------------
City | OCEAN SPRINGS
-----------------------------------------------------
State | MS
-----------------------------------------------------
Zip | 39564-2815
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 228-217-2997
-----------------------------------------------------
Fax | 228-250-1399
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER/MANAGER
-----------------------------------------------------
Name | MRS. AMANDA NICOLE KOPP
-----------------------------------------------------
Credential | MA, BCBA, IBA, LBA
-----------------------------------------------------
Telephone | 228-217-2997
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 103K00000X
-----------------------------------------------------
Taxonomy Name | Behavior Analyst
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------