Provider Demographics
NPI:1891313516
Name:POWELL, MI'TALIA SHANICE (BS)
Entity Type:Individual
Prefix:
First Name:MI'TALIA
Middle Name:SHANICE
Last Name:POWELL
Suffix:
Gender:F
Credentials:BS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:841 JIMMY ANN DR
Mailing Address - Street 2:
Mailing Address - City:DAYTONA BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32117-4583
Mailing Address - Country:US
Mailing Address - Phone:386-425-3900
Mailing Address - Fax:
Practice Address - Street 1:841 JIMMY ANN DR
Practice Address - Street 2:
Practice Address - City:DAYTONA BEACH
Practice Address - State:FL
Practice Address - Zip Code:32117-4583
Practice Address - Country:US
Practice Address - Phone:386-425-3900
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-07-09
Last Update Date:2021-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
106S00000X
FLCBHCMP101944171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician