Provider Demographics
NPI:1013581651
Name:EMPOWERMENT WITH GRACE LLC
Entity Type:Organization
Organization Name:EMPOWERMENT WITH GRACE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:PAMELA
Authorized Official - Middle Name:G
Authorized Official - Last Name:RILEY
Authorized Official - Suffix:
Authorized Official - Credentials:PHD, LPC
Authorized Official - Phone:814-332-0359
Mailing Address - Street 1:7145 MIKE WOOD BLVD
Mailing Address - Street 2:
Mailing Address - City:CONNEAUT LAKE
Mailing Address - State:PA
Mailing Address - Zip Code:16316-6527
Mailing Address - Country:US
Mailing Address - Phone:814-332-0359
Mailing Address - Fax:
Practice Address - Street 1:941 FEDERAL CT STE 104
Practice Address - Street 2:
Practice Address - City:MEADVILLE
Practice Address - State:PA
Practice Address - Zip Code:16335-3232
Practice Address - Country:US
Practice Address - Phone:814-332-0359
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-05-18
Last Update Date:2021-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1030215260003Medicaid