Provider Demographics
NPI:1215574900
Name:POWELL, MATTHEW ALLEN
Entity Type:Individual
Prefix:
First Name:MATTHEW
Middle Name:ALLEN
Last Name:POWELL
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9714 HEALTHWAY DR
Mailing Address - Street 2:
Mailing Address - City:BERLIN
Mailing Address - State:MD
Mailing Address - Zip Code:21811-1154
Mailing Address - Country:US
Mailing Address - Phone:410-641-3340
Mailing Address - Fax:
Practice Address - Street 1:100 E CARROLL ST
Practice Address - Street 2:
Practice Address - City:SALISBURY
Practice Address - State:MD
Practice Address - Zip Code:21801-5422
Practice Address - Country:US
Practice Address - Phone:410-726-8308
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-12-02
Last Update Date:2021-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD214321041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD21432OtherMARYLAND BOARD OF SOCIAL WORK