Provider Demographics
NPI:1730655549
Name:POWELL, MARIAH S (HIGH SCHOOL DIPLOMA)
Entity Type:Individual
Prefix:
First Name:MARIAH
Middle Name:S
Last Name:POWELL
Suffix:
Gender:F
Credentials:HIGH SCHOOL DIPLOMA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1601 S DE ANZA BLVD STE 110
Mailing Address - Street 2:
Mailing Address - City:CUPERTINO
Mailing Address - State:CA
Mailing Address - Zip Code:95014-5358
Mailing Address - Country:US
Mailing Address - Phone:669-258-9059
Mailing Address - Fax:
Practice Address - Street 1:1601 S DE ANZA BLVD STE 110
Practice Address - Street 2:
Practice Address - City:CUPERTINO
Practice Address - State:CA
Practice Address - Zip Code:95014-5358
Practice Address - Country:US
Practice Address - Phone:669-258-9059
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-10-18
Last Update Date:2018-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAF2774681103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst