Provider Demographics
NPI:1477591550
Name:POWELL, PENNI ACKERMAN (MSW, LCSW)
Entity Type:Individual
Prefix:MS
First Name:PENNI
Middle Name:ACKERMAN
Last Name:POWELL
Suffix:
Gender:F
Credentials:MSW, LCSW
Other - Prefix:
Other - First Name:PENNI
Other - Middle Name:ACKERMAN
Other - Last Name:WALLAS
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:2012 DILWORTH RD W
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28203-5732
Mailing Address - Country:US
Mailing Address - Phone:704-343-0820
Mailing Address - Fax:
Practice Address - Street 1:1717 CLEVELAND AVE
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28203-4735
Practice Address - Country:US
Practice Address - Phone:704-372-8004
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-02
Last Update Date:2007-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCC0005361041C0700X
NC255106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC8538AOtherBLUE CROSS NC
NC8538AOtherBLUE CROSS NC