Provider Demographics
NPI:1639591068
Name:POWELL, MARA
Entity Type:Individual
Prefix:MRS
First Name:MARA
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 1:101 E 16TH ST
Mailing Address - Street 2:2C
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10003-2114
Mailing Address - Country:US
Mailing Address - Phone:516-729-0226
Mailing Address - Fax:
Practice Address - Street 1:101 E 16TH ST
Practice Address - Street 2:2C
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10003-2114
Practice Address - Country:US
Practice Address - Phone:516-729-0226
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-01-21
Last Update Date:2014-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY564722111174400000X
NY564721111174400000X
NY564720111174400000X
NY564719111174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist