Provider Demographics
NPI:1487006128
Name:POWELL, TERRISSA
Entity Type:Individual
Prefix:
First Name:TERRISSA
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 1:3671 BUSINESS DR.
Mailing Address - Street 2:
Mailing Address - City:SACRAMENTO
Mailing Address - State:CA
Mailing Address - Zip Code:95820
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3671 BUSINESS DRIVE
Practice Address - Street 2:SUITE 110
Practice Address - City:SACRAMENTO
Practice Address - State:CA
Practice Address - Zip Code:95820
Practice Address - Country:US
Practice Address - Phone:916-734-8396
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-07-06
Last Update Date:2017-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
CA77337104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program