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General NPI Number Information
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NPI Number | 1831653021
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Entity Type | Organization
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Legal Business Name | EMPOWERED LIVING PSYCHOLOGICAL SERVICES, INC.
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Dates
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Enumeration Date | 01/22/2019
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Last Update Date | 04/28/2021
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Provider Practice Location Address
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Address Line | 9113 FOOTHILL BLVD STE 130
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City | RANCHO CUCAMONGA
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State | CA
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Zip | 91730-6565
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Country | US
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Telephone | 909-652-0361
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Fax | 909-652-0241
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Provider Business Mailing Address
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Address Line | 9113 FOOTHILL BLVD STE 130
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City | RANCHO CUCAMONGA
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State | CA
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Zip | 91730-6565
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Country | US
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Telephone | 909-652-0361
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Fax | 909-652-0241
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Authorized Official
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Title or Position | CEO/ CLINICAL PSYCHOLOGIST
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Name | DR. STEFANIE LOCKHART-PETTAWAY
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Credential | PSY.D
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Telephone | 909-652-0361
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 103T00000X
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Taxonomy Name | Psychologist
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License Number |
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License Number State |
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