Provider Demographics
NPI:1740833714
Name:POWERS, ELIZABETH MICHELLE
Entity type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:MICHELLE
Last Name:POWERS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:LISA
Other - Middle Name:
Other - Last Name:POWERS
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:1060 S 3RD ST APT 175
Mailing Address - Street 2:
Mailing Address - City:SAN JOSE
Mailing Address - State:CA
Mailing Address - Zip Code:95112-3980
Mailing Address - Country:US
Mailing Address - Phone:408-694-2201
Mailing Address - Fax:
Practice Address - Street 1:1171 HOMESTEAD RD STE 250
Practice Address - Street 2:
Practice Address - City:SANTA CLARA
Practice Address - State:CA
Practice Address - Zip Code:95050-5485
Practice Address - Country:US
Practice Address - Phone:408-320-2590
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-07-18
Last Update Date:2019-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician