MEDICARE: EMPOWERED THROUGH PLAY LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	251S00000X	Community/Behavioral Health Agency
2	101YM0800X	Mental Health Counselor		ID

General Provider Information

NPI Number	:	1033588207
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	EMPOWERED THROUGH PLAY LLC

Provider Business Mailing Address
First Line	:	560 W CANFIELD AVE
Second Line	:	STE 300
City	:	COEUR D ALENE
State	:	ID
Zip	:	83815-7950
Country	:	US
Telephone Number	:	208-758-7111
Fax Number	:

Provider Business Practice Location Address
First Line	:	560 W CANFIELD AVE
Second Line	:	STE 300
City	:	COEUR D ALENE
State	:	ID
Zip	:	83815-7950
Country	:	US
Telephone Number	:	208-758-7111
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	STACIA CARR PETERSON
Credential	:	LCPC
Telephone Number	:	208-758-7111

Provider Enumeration Date	:	09/17/2015
Last Update Date	:	08/16/2016

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Directions to “EMPOWERED THROUGH PLAY LLC ” Practice Location

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