=====================================================
General NPI Number Information
=====================================================
NPI Number | 1710702204
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | EMPOWERED LEGACY CENTER
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/19/2024
-----------------------------------------------------
Last Update Date | 12/06/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1200 HARTFORD AVE STE 3B
-----------------------------------------------------
City | JOHNSTON
-----------------------------------------------------
State | RI
-----------------------------------------------------
Zip | 02919-7143
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 401-263-0778
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1200 HARTFORD AVE STE 3B
-----------------------------------------------------
City | JOHNSTON
-----------------------------------------------------
State | RI
-----------------------------------------------------
Zip | 02919-7143
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 401-263-0778
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | THERAPIST
-----------------------------------------------------
Name | FRANK LUDERS PAUL
-----------------------------------------------------
Credential | LICSW
-----------------------------------------------------
Telephone | 401-263-0778
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QM0801X
-----------------------------------------------------
Taxonomy Name | Mental Health Clinic/Center (Including Community Mental Health Center)
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 103TC0700X
-----------------------------------------------------
Taxonomy Name | Clinical Psychologist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------