Provider Demographics
NPI:1619320181
Name:POWELL, WALITA
Entity Type:Individual
Prefix:
First Name:WALITA
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 1:2821 CROW CANYON ROAD, SUITE 101
Mailing Address - Street 2:
Mailing Address - City:SAN RAMON
Mailing Address - State:CA
Mailing Address - Zip Code:94583-1659
Mailing Address - Country:US
Mailing Address - Phone:925-364-4515
Mailing Address - Fax:
Practice Address - Street 1:2821 CROW CANYON ROAD
Practice Address - Street 2:SUITE 101
Practice Address - City:SAN RAMON
Practice Address - State:CA
Practice Address - Zip Code:94583
Practice Address - Country:US
Practice Address - Phone:925-364-4515
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-07-19
Last Update Date:2018-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician