Basic Information
| Provider Information | |||||||||
| NPI: | 1447490073 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | EMPOWERMENT CLINIC INC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 150 NE 3RD AVE STE A | ||||||||
| Address2: | |||||||||
| City: | HILLSBORO | ||||||||
| State: | OR | ||||||||
| PostalCode: | 971243150 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5038510059 | ||||||||
| FaxNumber: | 5034305403 | ||||||||
| Practice Location | |||||||||
| Address1: | 5257 NE MARTIN LUTHER KING JR BLVD STE 201&202 | ||||||||
| Address2: | |||||||||
| City: | PORTLAND | ||||||||
| State: | OR | ||||||||
| PostalCode: | 972113282 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5036763710 | ||||||||
| FaxNumber: | 5034305403 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/23/2009 | ||||||||
| LastUpdateDate: | 06/11/2019 | ||||||||
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| AuthorizedOfficialLastName: | BRAXTON | ||||||||
| AuthorizedOfficialFirstName: | MICHAEL | ||||||||
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| AuthorizedOfficialTitleorPosition: | EXECUTIVE DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 5036763710 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MSW, CADC III, QMHP | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YA0400X | 2800 | OR | N | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) | 101YM0800X | 2800 | OR | N | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Counselor | Mental Health | 104100000X | OR | N | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Social Worker | 172V00000X | 2800 | OR | N | 193200000X MULTI-SPECIALTY GROUP | Other Service Providers | Community Health Worker | 183500000X | OR | N | 193200000X MULTI-SPECIALTY GROUP | Pharmacy Service Providers | Pharmacist | 251V00000X | OR | N | Agencies | Voluntary or Charitable | 261QF0400X | OR | N | Ambulatory Health Care Facilities | Clinic/Center | Federally Qualified Health Center (FQHC) | 261QM0801X | 2800 | OR | N | Ambulatory Health Care Facilities | Clinic/Center | Mental Health (Including Community Mental Health Center) | 261QP3300X | 2800 | OR | N | Ambulatory Health Care Facilities | Clinic/Center | Pain | 363LC1500X | 20105014NP | OR | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Community Health | 363LP2300X | 20105014NP | OR | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Primary Care | 261QC1500X | OR | Y | Ambulatory Health Care Facilities | Clinic/Center | Community Health |
ID Information
| ID | Type | State | Issuer | Description | 1447490073 | 05 | OR | MEDICAID | 50071465 | 05 | OR | MEDICAID |