MEDICARE: EMBRACE TO EMPOWER WELLNESS CENTER

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	2084P0804X	Child & Adolescent Psychiatry Physician

General Provider Information

NPI Number	:	1548775273
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	EMBRACE TO EMPOWER WELLNESS CENTER

Provider Business Mailing Address
First Line	:	4720 CLEVELAND HEIGHTS BLVD STE 305
Second Line	:
City	:	LAKELAND
State	:	FL
Zip	:	33813-2246
Country	:	US
Telephone Number	:	863-937-5599
Fax Number	:	863-816-5403

Provider Business Practice Location Address
First Line	:	4720 CLEVELAND HEIGHTS BLVD STE 305
Second Line	:
City	:	LAKELAND
State	:	FL
Zip	:	33813-2246
Country	:	US
Telephone Number	:	863-937-5599
Fax Number	:	863-816-5403

Authorized Official
Title or Position	:	PSYCHIATRIST
Name	:	LATAMIA M WHITE-GREEN
Credential	:	MD
Telephone Number	:	863-937-5599

Provider Enumeration Date	:	12/04/2017
Last Update Date	:	12/04/2017

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