Provider Demographics
NPI:1114041332
Name:EMPOWERMENT THROUGH ADVENTURE LLC
Entity Type:Organization
Organization Name:EMPOWERMENT THROUGH ADVENTURE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MS
Authorized Official - First Name:JENNIFER
Authorized Official - Middle Name:K
Authorized Official - Last Name:WIRTH
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:609-828-2110
Mailing Address - Street 1:86 ELGIN AVENUE
Mailing Address - Street 2:
Mailing Address - City:WESTMONT
Mailing Address - State:NJ
Mailing Address - Zip Code:08108
Mailing Address - Country:US
Mailing Address - Phone:609-828-2110
Mailing Address - Fax:856-869-2830
Practice Address - Street 1:86 ELGIN AVENUE
Practice Address - Street 2:
Practice Address - City:WESTMONT
Practice Address - State:NJ
Practice Address - Zip Code:08108
Practice Address - Country:US
Practice Address - Phone:609-828-2110
Practice Address - Fax:856-854-5423
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-16
Last Update Date:2008-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ44SC052304001041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ0037494Medicaid
NJ0030856Medicaid
NJ0031101Medicaid