Provider Demographics
NPI:1558978866
Name:POWERS, KATHLEEN MARY
Entity Type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:MARY
Last Name:POWERS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:KATHLEEN
Other - Middle Name:MARY
Other - Last Name:HALES
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:900 WILKINSON ST
Mailing Address - Street 2:
Mailing Address - City:MANDEVILLE
Mailing Address - State:LA
Mailing Address - Zip Code:70448-3533
Mailing Address - Country:US
Mailing Address - Phone:985-624-4456
Mailing Address - Fax:
Practice Address - Street 1:900 WILKINSON ST
Practice Address - Street 2:
Practice Address - City:MANDEVILLE
Practice Address - State:LA
Practice Address - Zip Code:70448-3533
Practice Address - Country:US
Practice Address - Phone:985-624-4456
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-09-30
Last Update Date:2021-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
175T00000X
LA101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1154750644Medicaid