MEDICARE: TIESHA G POWELL CDCA

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YA0400X	Addiction (Substance Use Disorder) Counselor	CDCA.172483	OH

General Provider Information

NPI Number	:	1679049233
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	TIESHA G POWELL CDCA

Provider Business Mailing Address
First Line	:	1 N COMMERCE PARK DR # 318
Second Line	:
City	:	CINCINNATI
State	:	OH
Zip	:	45215-3187
Country	:	US
Telephone Number	:	513-761-0158
Fax Number	:

Provider Business Practice Location Address
First Line	:	1 N COMMERCE PARK DR # 318
Second Line	:
City	:	CINCINNATI
State	:	OH
Zip	:	45215-3187
Country	:	US
Telephone Number	:	513-761-0158
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/22/2018
Last Update Date	:	01/09/2020

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