Provider Demographics
NPI:1548572415
Name:EMPOWERED2CHANGE LLC
Entity Type:Organization
Organization Name:EMPOWERED2CHANGE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:SHA-RHONDA
Authorized Official - Middle Name:MICHEA
Authorized Official - Last Name:DAVIS
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW, SSW
Authorized Official - Phone:678-602-9709
Mailing Address - Street 1:PO BOX 1365
Mailing Address - Street 2:
Mailing Address - City:HIRAM
Mailing Address - State:GA
Mailing Address - Zip Code:30141-1365
Mailing Address - Country:US
Mailing Address - Phone:678-602-9709
Mailing Address - Fax:678-928-9499
Practice Address - Street 1:5604 WENDY BAGWELL PKWY
Practice Address - Street 2:SUITE 812
Practice Address - City:HIRAM
Practice Address - State:GA
Practice Address - Zip Code:30141-7813
Practice Address - Country:US
Practice Address - Phone:678-602-9709
Practice Address - Fax:678-928-9499
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-07-08
Last Update Date:2011-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GACSW0034151041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty