Provider Demographics
NPI:1124624697
Name:EMPOWER LICENSED BEHAVIOR ANALYST PLLC
Entity type:Organization
Organization Name:EMPOWER LICENSED BEHAVIOR ANALYST PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:PERI
Authorized Official - Middle Name:E
Authorized Official - Last Name:GOLDWURM
Authorized Official - Suffix:
Authorized Official - Credentials:BA
Authorized Official - Phone:718-702-7693
Mailing Address - Street 1:5213 19TH AVE
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11204-1602
Mailing Address - Country:US
Mailing Address - Phone:718-702-7693
Mailing Address - Fax:718-387-6429
Practice Address - Street 1:5213 19TH AVE
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11204-1602
Practice Address - Country:US
Practice Address - Phone:718-702-7693
Practice Address - Fax:718-387-6429
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-12-09
Last Update Date:2020-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/CenterGroup - Multi-Specialty
No103K00000XBehavioral Health & Social Service ProvidersBehavior AnalystGroup - Multi-Specialty