Provider Demographics
NPI:1760125942
Name:POWELL, NICOLE MARIE
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:MARIE
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 1:185 HAMPTON VILLAGE RD
Mailing Address - Street 2:
Mailing Address - City:MADISON
Mailing Address - State:VA
Mailing Address - Zip Code:22727-3849
Mailing Address - Country:US
Mailing Address - Phone:703-798-6829
Mailing Address - Fax:
Practice Address - Street 1:27 JACKS SHOP RD
Practice Address - Street 2:
Practice Address - City:ROCHELLE
Practice Address - State:VA
Practice Address - Zip Code:22738-4061
Practice Address - Country:US
Practice Address - Phone:540-738-7720
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-04-15
Last Update Date:2022-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician