Provider Demographics
NPI:1568109619
Name:POWELL, AUNDRA (CAC11087)
Entity Type:Individual
Prefix:
First Name:AUNDRA
Middle Name:
Last Name:POWELL
Suffix:
Gender:M
Credentials:CAC11087
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1516 OLIVE ST NE
Mailing Address - Street 2:
Mailing Address - City:WASHINGTON
Mailing Address - State:DC
Mailing Address - Zip Code:20019-2715
Mailing Address - Country:US
Mailing Address - Phone:202-276-0542
Mailing Address - Fax:
Practice Address - Street 1:2904 WEST AVE
Practice Address - Street 2:
Practice Address - City:DISTRICT HEIGHTS
Practice Address - State:MD
Practice Address - Zip Code:20747-2746
Practice Address - Country:US
Practice Address - Phone:202-276-0542
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-05-18
Last Update Date:2022-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DCCAC11087101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
DC101YA0400XMedicaid