MEDICARE: EMPOWERED: ABA THERAPY AND CONSULTATIVE SERVICES

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	103K00000X	Behavior Analyst

General Provider Information

NPI Number	:	1477010825
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	EMPOWERED: ABA THERAPY AND CONSULTATIVE SERVICES

Provider Business Mailing Address
First Line	:	9307 N LAKE DR SW
Second Line	:
City	:	LAKEWOOD
State	:	WA
Zip	:	98498-1135
Country	:	US
Telephone Number	:	253-370-8173
Fax Number	:

Provider Business Practice Location Address
First Line	:	9307 N LAKE DR SW
Second Line	:
City	:	LAKEWOOD
State	:	WA
Zip	:	98498-1135
Country	:	US
Telephone Number	:	253-370-8173
Fax Number	:

Authorized Official
Title or Position	:	BOARD CERTIFIED BEHAVIOR ANALYST
Name	:	JESIKA MILLER
Credential	:	M.S., LBA, BCBA
Telephone Number	:	253-344-4390

Provider Enumeration Date	:	02/21/2019
Last Update Date	:	05/30/2019

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