Provider Demographics
NPI:1740380864
Name:POWELL, CAROLYN SIE (PA)
Entity Type:Individual
Prefix:
First Name:CAROLYN
Middle Name:SIE
Last Name:POWELL
Suffix:
Gender:F
Credentials:PA
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 790
Mailing Address - Street 2:
Mailing Address - City:ASHLAND
Mailing Address - State:KY
Mailing Address - Zip Code:41105-0790
Mailing Address - Country:US
Mailing Address - Phone:606-329-8588
Mailing Address - Fax:606-329-8195
Practice Address - Street 1:300 FOXGLOVE DR
Practice Address - Street 2:
Practice Address - City:MT STERLING
Practice Address - State:KY
Practice Address - Zip Code:40353-9769
Practice Address - Country:US
Practice Address - Phone:859-498-2135
Practice Address - Fax:606-498-7547
Is Sole Proprietor?:No
Enumeration Date:2006-09-25
Last Update Date:2014-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY0797103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY30610026Medicaid
11645498OtherCAQH
000000354336OtherANTHEM BCBS