Provider Demographics
NPI:1164569240
Name:POWELL, TONYA (LPC)
Entity Type:Individual
Prefix:
First Name:TONYA
Middle Name:
Last Name:POWELL
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:413 HISTORIC 66 W
Mailing Address - Street 2:
Mailing Address - City:WAYNESVILLE
Mailing Address - State:MO
Mailing Address - Zip Code:65583-2114
Mailing Address - Country:US
Mailing Address - Phone:573-774-4198
Mailing Address - Fax:573-774-4951
Practice Address - Street 1:413 HISTORIC 66 W
Practice Address - Street 2:
Practice Address - City:WAYNESVILLE
Practice Address - State:MO
Practice Address - Zip Code:65583-2114
Practice Address - Country:US
Practice Address - Phone:573-774-4198
Practice Address - Fax:573-774-4951
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-30
Last Update Date:2009-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2006024099101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO493734701Medicaid