Provider Demographics
NPI:1851467617
Name:POWELL, PATRICIA M (LCSW,ACSW,BCD)
Entity Type:Individual
Prefix:
First Name:PATRICIA
Middle Name:M
Last Name:POWELL
Suffix:
Gender:F
Credentials:LCSW,ACSW,BCD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9089 BASELINE RD STE 200
Mailing Address - Street 2:
Mailing Address - City:RANCHO CUCAMONGA
Mailing Address - State:CA
Mailing Address - Zip Code:91730-1295
Mailing Address - Country:US
Mailing Address - Phone:909-980-3567
Mailing Address - Fax:909-980-3567
Practice Address - Street 1:9089 BASELINE RD STE 200
Practice Address - Street 2:
Practice Address - City:RANCHO CUCAMONGA
Practice Address - State:CA
Practice Address - Zip Code:91730-1295
Practice Address - Country:US
Practice Address - Phone:909-980-3567
Practice Address - Fax:909-980-3567
Is Sole Proprietor?:No
Enumeration Date:2006-11-24
Last Update Date:2012-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YS0200X
CALCS167941041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YS0200XBehavioral Health & Social Service ProvidersCounselorSchool
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAZZZ000235ZMedicare ID - Type Unspecified