Provider Demographics
NPI:1033588207
Name:EMPOWERED THROUGH PLAY LLC
Entity Type:Organization
Organization Name:EMPOWERED THROUGH PLAY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:STACIA
Authorized Official - Middle Name:
Authorized Official - Last Name:CARR PETERSON
Authorized Official - Suffix:
Authorized Official - Credentials:LCPC
Authorized Official - Phone:208-758-7111
Mailing Address - Street 1:560 W CANFIELD AVE
Mailing Address - Street 2:STE 300
Mailing Address - City:COEUR D ALENE
Mailing Address - State:ID
Mailing Address - Zip Code:83815-7950
Mailing Address - Country:US
Mailing Address - Phone:208-758-7111
Mailing Address - Fax:
Practice Address - Street 1:560 W CANFIELD AVE
Practice Address - Street 2:STE 300
Practice Address - City:COEUR D ALENE
Practice Address - State:ID
Practice Address - Zip Code:83815-7950
Practice Address - Country:US
Practice Address - Phone:208-758-7111
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-09-17
Last Update Date:2016-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID101YM0800X
251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty
No251S00000XAgenciesCommunity/Behavioral HealthGroup - Single Specialty