Provider Demographics
NPI:1689992323
Name:POWERS, CONNIE J
Entity Type:Individual
Prefix:
First Name:CONNIE
Middle Name:J
Last Name:POWERS
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:PO BOX 1062
Mailing Address - Street 2:
Mailing Address - City:HAYWARD
Mailing Address - State:WI
Mailing Address - Zip Code:54843-1062
Mailing Address - Country:US
Mailing Address - Phone:715-373-0160
Mailing Address - Fax:715-373-0162
Practice Address - Street 1:10045 N STATE ROAD 27
Practice Address - Street 2:
Practice Address - City:HAYWARD
Practice Address - State:WI
Practice Address - Zip Code:54843-3525
Practice Address - Country:US
Practice Address - Phone:715-373-0160
Practice Address - Fax:715-373-0162
Is Sole Proprietor?:No
Enumeration Date:2010-05-05
Last Update Date:2010-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI399-226101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor