Healthcare Provider Details

I. General information

NPI: 1215163316
Provider Name (Legal Business Name): BENNY LEE POWELL MDIV, LCAC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/03/2009
Last Update Date: 10/26/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2100 GOSHEN RD
FORT WAYNE IN
46808-1493
US

IV. Provider business mailing address

850 N HARRISON ST ATTN: ANNE LAWSON - CREDENTIALING
WARSAW IN
46580-3163
US

V. Phone/Fax

Practice location:
  • Phone: 240-471-3500
  • Fax: 260-471-4263
Mailing address:
  • Phone: 574-267-7169
  • Fax: 574-269-0597

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number87000082A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: