Provider Demographics
NPI:1679841597
Name:POWELL, MICHELLE
Entity Type:Individual
Prefix:MS
First Name:MICHELLE
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 1:541 DUSTY LN
Mailing Address - Street 2:
Mailing Address - City:MACON
Mailing Address - State:GA
Mailing Address - Zip Code:31211-7517
Mailing Address - Country:US
Mailing Address - Phone:478-722-8046
Mailing Address - Fax:
Practice Address - Street 1:541 DUSTY LN
Practice Address - Street 2:
Practice Address - City:MACON
Practice Address - State:GA
Practice Address - Zip Code:31211-7517
Practice Address - Country:US
Practice Address - Phone:478-722-8046
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-12-06
Last Update Date:2011-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA003625101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional