Provider Demographics
NPI:1437778750
Name:CUCCHIELLA, POWELL
Entity Type:Individual
Prefix:
First Name:POWELL
Middle Name:
Last Name:CUCCHIELLA
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 1:12 BEACON ST
Mailing Address - Street 2:
Mailing Address - City:BALLSTON SPA
Mailing Address - State:NY
Mailing Address - Zip Code:12020-3602
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:260 WASHINGTON AVENUE EXT STE 101
Practice Address - Street 2:
Practice Address - City:ALBANY
Practice Address - State:NY
Practice Address - Zip Code:12203-6326
Practice Address - Country:US
Practice Address - Phone:518-218-1188
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-04-16
Last Update Date:2020-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY009730101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health