=====================================================
General NPI Number Information
=====================================================
NPI Number | 1467258939
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | EMPOWERED PELVIC THERAPY LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/24/2025
-----------------------------------------------------
Last Update Date | 10/06/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 160 SUMMIT AVE STE 204
-----------------------------------------------------
City | MONTVALE
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 07645-1763
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 201-305-0130
-----------------------------------------------------
Fax | 833-538-0115
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 160 SUMMIT AVE STE 204
-----------------------------------------------------
City | MONTVALE
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 07645-1763
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 201-305-0130
-----------------------------------------------------
Fax | 833-538-0115
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | CARLY GOSSARD
-----------------------------------------------------
Credential | PT, DPT, OCS, PRPC
-----------------------------------------------------
Telephone | 201-305-0130
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225X00000X
-----------------------------------------------------
Taxonomy Name | Occupational Therapist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------