Provider Demographics
NPI:1356891709
Name:POWELL, PENNY GOODS (CSW)
Entity type:Individual
Prefix:
First Name:PENNY
Middle Name:GOODS
Last Name:POWELL
Suffix:
Gender:F
Credentials:CSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3314 HWY 594 LOT 16
Mailing Address - Street 2:
Mailing Address - City:MONROE
Mailing Address - State:LA
Mailing Address - Zip Code:71203
Mailing Address - Country:US
Mailing Address - Phone:318-953-3610
Mailing Address - Fax:
Practice Address - Street 1:3314 HWY 594 LOT 16
Practice Address - Street 2:
Practice Address - City:MONROE
Practice Address - State:LA
Practice Address - Zip Code:71203
Practice Address - Country:US
Practice Address - Phone:318-953-3610
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-10-10
Last Update Date:2016-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA13376101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health