Provider Demographics
NPI:1093952244
Name:POWELL, TERRI YVETTE
Entity Type:Individual
Prefix:
First Name:TERRI
Middle Name:YVETTE
Last Name:POWELL
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1897 W JEFFERSON BLVD STE A
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90018-3434
Mailing Address - Country:US
Mailing Address - Phone:323-735-2390
Mailing Address - Fax:323-735-2390
Practice Address - Street 1:1897 W JEFFERSON BLVD STE A
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90018-3434
Practice Address - Country:US
Practice Address - Phone:323-735-2390
Practice Address - Fax:323-735-2390
Is Sole Proprietor?:Yes
Enumeration Date:2009-01-09
Last Update Date:2009-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA3245S0500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3245S0500XResidential Treatment FacilitiesSubstance Abuse Rehabilitation FacilitySubstance Abuse Treatment, Children