Provider Demographics
NPI:1205481843
Name:EMPOWERED LIFE LLC
Entity type:Organization
Organization Name:EMPOWERED LIFE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER, THERAPIST
Authorized Official - Prefix:
Authorized Official - First Name:KATHERINE
Authorized Official - Middle Name:
Authorized Official - Last Name:ROTH
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:248-761-3284
Mailing Address - Street 1:709 W BAY ST
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33606-2705
Mailing Address - Country:US
Mailing Address - Phone:813-658-8071
Mailing Address - Fax:813-820-0404
Practice Address - Street 1:709 W BAY ST
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33606-2705
Practice Address - Country:US
Practice Address - Phone:813-658-8071
Practice Address - Fax:813-820-0404
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-08-08
Last Update Date:2019-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL1366981946OtherPROVIDER NPI
FL1316290372OtherINDIVIDUAL NPI