Provider Demographics
NPI:1891443776
Name:POWELL, STAISHA
Entity Type:Individual
Prefix:
First Name:STAISHA
Middle Name:
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 1:2472 JETT FERRY RD
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30338-3059
Mailing Address - Country:US
Mailing Address - Phone:678-691-2206
Mailing Address - Fax:
Practice Address - Street 1:2472 JETT FERRY RD
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30338-3059
Practice Address - Country:US
Practice Address - Phone:678-691-2206
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-03-10
Last Update Date:2022-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
106S00000X
GA22-208277106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician