Healthcare Provider Details

I. General information

NPI: 1134451362
Provider Name (Legal Business Name): LYNETTE POWERS CCC-SLP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/15/2010
Last Update Date: 02/15/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3357 WARE ST
BLACKSHEAR GA
31516-6111
US

IV. Provider business mailing address

816 FORESTWOOD DR
MINNEOLA FL
34715-7723
US

V. Phone/Fax

Practice location:
  • Phone: 912-449-5615
  • Fax: 407-264-6557
Mailing address:
  • Phone: 352-536-2561
  • Fax: 407-264-6557

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License NumberSLP004423
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: