Provider Demographics
NPI:1710702204
Name:EMPOWERED LEGACY CENTER
Entity type:Organization
Organization Name:EMPOWERED LEGACY CENTER
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:THERAPIST
Authorized Official - Prefix:
Authorized Official - First Name:FRANK
Authorized Official - Middle Name:LUDERS
Authorized Official - Last Name:PAUL
Authorized Official - Suffix:
Authorized Official - Credentials:LICSW
Authorized Official - Phone:401-263-0778
Mailing Address - Street 1:1200 HARTFORD AVE STE 3B
Mailing Address - Street 2:
Mailing Address - City:JOHNSTON
Mailing Address - State:RI
Mailing Address - Zip Code:02919-7143
Mailing Address - Country:US
Mailing Address - Phone:401-263-0778
Mailing Address - Fax:
Practice Address - Street 1:1200 HARTFORD AVE STE 3B
Practice Address - Street 2:
Practice Address - City:JOHNSTON
Practice Address - State:RI
Practice Address - Zip Code:02919-7143
Practice Address - Country:US
Practice Address - Phone:401-263-0778
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-11-19
Last Update Date:2024-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Multi-Specialty
No261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)Group - Multi-Specialty