Provider Demographics
NPI:1669714002
Name:POWERS, PAMELA SUE (LCSW, CAP, CCTP)
Entity type:Individual
Prefix:MS
First Name:PAMELA
Middle Name:SUE
Last Name:POWERS
Suffix:
Gender:F
Credentials:LCSW, CAP, CCTP
Other - Prefix:MRS
Other - First Name:PAMELA
Other - Middle Name:SUE
Other - Last Name:DISPONETT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:CAP
Mailing Address - Street 1:412 SPANISH MOSS TRL
Mailing Address - Street 2:
Mailing Address - City:DESTIN
Mailing Address - State:FL
Mailing Address - Zip Code:32541-2605
Mailing Address - Country:US
Mailing Address - Phone:850-803-0079
Mailing Address - Fax:
Practice Address - Street 1:51B YACHT CLUB DR NE
Practice Address - Street 2:
Practice Address - City:FORT WALTON BEACH
Practice Address - State:FL
Practice Address - Zip Code:32548-4473
Practice Address - Country:US
Practice Address - Phone:850-664-0145
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-03-25
Last Update Date:2013-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL3067101YA0400X
FLSW 110741041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)