Provider Demographics
NPI:1356093280
Name:POWELL, CAROLYN
Entity Type:Individual
Prefix:
First Name:CAROLYN
Middle Name:
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 1:7115 SW MOLALLA BEND RD
Mailing Address - Street 2:
Mailing Address - City:WILSONVILLE
Mailing Address - State:OR
Mailing Address - Zip Code:97070-7439
Mailing Address - Country:US
Mailing Address - Phone:503-550-0319
Mailing Address - Fax:
Practice Address - Street 1:7929 SW CIRRUS DR # 23
Practice Address - Street 2:
Practice Address - City:BEAVERTON
Practice Address - State:OR
Practice Address - Zip Code:97008-5971
Practice Address - Country:US
Practice Address - Phone:503-644-2339
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-01-21
Last Update Date:2022-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health