Provider Demographics
NPI:1275195794
Name:POWELL, JUDY A (MS, LADC)
Entity Type:Individual
Prefix:
First Name:JUDY
Middle Name:A
Last Name:POWELL
Suffix:
Gender:F
Credentials:MS, LADC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:570 SETTLERS RIDGE PKWY UNIT C204
Mailing Address - Street 2:
Mailing Address - City:WOODBURY
Mailing Address - State:MN
Mailing Address - Zip Code:55129-7519
Mailing Address - Country:US
Mailing Address - Phone:651-283-4143
Mailing Address - Fax:
Practice Address - Street 1:570 SETTLERS RIDGE PKWY UNIT C204
Practice Address - Street 2:
Practice Address - City:WOODBURY
Practice Address - State:MN
Practice Address - Zip Code:55129-7519
Practice Address - Country:US
Practice Address - Phone:651-283-4143
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-07-04
Last Update Date:2020-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN300611101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)