Provider Demographics
NPI:1508069683
Name:POWELL, MICHAEL ANTONIO
Entity Type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:ANTONIO
Last Name:POWELL
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 1:101 N COURT SQ
Mailing Address - Street 2:OFFICE 18
Mailing Address - City:LUMBERTON
Mailing Address - State:NC
Mailing Address - Zip Code:28358-5579
Mailing Address - Country:US
Mailing Address - Phone:910-536-5636
Mailing Address - Fax:
Practice Address - Street 1:101 N COURT SQ
Practice Address - Street 2:OFFICE 18
Practice Address - City:LUMBERTON
Practice Address - State:NC
Practice Address - Zip Code:28358-5579
Practice Address - Country:US
Practice Address - Phone:910-536-5636
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-07
Last Update Date:2013-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC6620101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional