Provider Demographics
NPI:1013222967
Name:POWELL, MIRANDA (LCSW)
Entity Type:Individual
Prefix:
First Name:MIRANDA
Middle Name:
Last Name:POWELL
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3550 SE WOODWARD ST
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97202-1552
Mailing Address - Country:US
Mailing Address - Phone:503-517-8663
Mailing Address - Fax:
Practice Address - Street 1:3550 SE WOODWARD ST
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97202-1552
Practice Address - Country:US
Practice Address - Phone:503-517-8663
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-08-16
Last Update Date:2010-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORL45881041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical