Provider Demographics
NPI:1831885359
Name:WILD EMPOWERMENT LLC
Entity type:Organization
Organization Name:WILD EMPOWERMENT LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER / CLINICIAN
Authorized Official - Prefix:
Authorized Official - First Name:GINA
Authorized Official - Middle Name:
Authorized Official - Last Name:AMANTE
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:203-951-1393
Mailing Address - Street 1:4 RESEARCH DR STE 402
Mailing Address - Street 2:
Mailing Address - City:SHELTON
Mailing Address - State:CT
Mailing Address - Zip Code:06484-6242
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4 RESEARCH DR STE 402
Practice Address - Street 2:
Practice Address - City:SHELTON
Practice Address - State:CT
Practice Address - Zip Code:06484-6242
Practice Address - Country:US
Practice Address - Phone:203-951-1393
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-04-17
Last Update Date:2023-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty