Provider Demographics
NPI:1194005637
Name:POWELL, TRACEY DOVE (MS, LPC)
Entity Type:Individual
Prefix:
First Name:TRACEY
Middle Name:DOVE
Last Name:POWELL
Suffix:
Gender:F
Credentials:MS, LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:44355 PREMIER PLZ
Mailing Address - Street 2:SUITE 120
Mailing Address - City:ASHBURN
Mailing Address - State:VA
Mailing Address - Zip Code:20147-5049
Mailing Address - Country:US
Mailing Address - Phone:703-655-4869
Mailing Address - Fax:
Practice Address - Street 1:44355 PREMIER PLZ
Practice Address - Street 2:SUITE 120
Practice Address - City:ASHBURN
Practice Address - State:VA
Practice Address - Zip Code:20147-5049
Practice Address - Country:US
Practice Address - Phone:703-655-4869
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-08-27
Last Update Date:2013-09-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0701005549101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health