MEDICARE: EMPOWER HER THERAPY

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	1041C0700X	Clinical Social Worker

General Provider Information

NPI Number	:	1275390205
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	EMPOWER HER THERAPY

Provider Business Mailing Address
First Line	:	W4795 DEER RUN DR
Second Line	:
City	:	BLACK CREEK
State	:	WI
Zip	:	54106-8175
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	W4795 DEER RUN DR
Second Line	:
City	:	BLACK CREEK
State	:	WI
Zip	:	54106-8175
Country	:	US
Telephone Number	:	920-205-6158
Fax Number	:

Authorized Official
Title or Position	:	CREDENTIALING MANAGER
Name	:	LESLIE ELMER
Credential	:	CPCS
Telephone Number	:	608-352-8323

Provider Enumeration Date	:	03/05/2024
Last Update Date	:	03/05/2024

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Directions to “EMPOWER HER THERAPY ” Practice Location

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