=====================================================
General NPI Number Information
=====================================================
NPI Number | 1093058257
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | EMBODYING REDEMPTION
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/05/2013
-----------------------------------------------------
Last Update Date | 10/16/2013
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 495 ORANGE ST
-----------------------------------------------------
City | NEW HAVEN
-----------------------------------------------------
State | CT
-----------------------------------------------------
Zip | 06511-3809
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 206-321-8555
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 872 STATE ST APT 3D
-----------------------------------------------------
City | NEW HAVEN
-----------------------------------------------------
State | CT
-----------------------------------------------------
Zip | 06511-7310
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 206-321-8555
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | MS. LAURA WALLACE
-----------------------------------------------------
Credential | LMFT
-----------------------------------------------------
Telephone | 206-321-8555
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 106H00000X
-----------------------------------------------------
Taxonomy Name | Marriage & Family Therapist
-----------------------------------------------------
License Number | 1470
-----------------------------------------------------
License Number State | CT
-----------------------------------------------------