Provider Demographics
NPI:1831653021
Name:EMPOWERED LIVING PSYCHOLOGICAL SERVICES, INC.
Entity Type:Organization
Organization Name:EMPOWERED LIVING PSYCHOLOGICAL SERVICES, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO/ CLINICAL PSYCHOLOGIST
Authorized Official - Prefix:DR
Authorized Official - First Name:STEFANIE
Authorized Official - Middle Name:
Authorized Official - Last Name:LOCKHART-PETTAWAY
Authorized Official - Suffix:
Authorized Official - Credentials:PSYD
Authorized Official - Phone:909-652-0361
Mailing Address - Street 1:9113 FOOTHILL BLVD STE 130
Mailing Address - Street 2:
Mailing Address - City:RANCHO CUCAMONGA
Mailing Address - State:CA
Mailing Address - Zip Code:91730-6565
Mailing Address - Country:US
Mailing Address - Phone:909-652-0361
Mailing Address - Fax:909-652-0241
Practice Address - Street 1:9113 FOOTHILL BLVD STE 130
Practice Address - Street 2:
Practice Address - City:RANCHO CUCAMONGA
Practice Address - State:CA
Practice Address - Zip Code:91730-6565
Practice Address - Country:US
Practice Address - Phone:909-652-0361
Practice Address - Fax:909-652-0241
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-01-22
Last Update Date:2021-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Multi-Specialty