Healthcare Provider Details

I. General information

NPI: 1841248853
Provider Name (Legal Business Name): DORETTA J. POWELL LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/04/2006
Last Update Date: 10/14/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1401 MADISON AVE
COVINGTON KY
41011-3313
US

IV. Provider business mailing address

1401 MADISON AVE
COVINGTON KY
41011-3313
US

V. Phone/Fax

Practice location:
  • Phone: 859-655-6100
  • Fax: 859-655-6240
Mailing address:
  • Phone: 859-655-6100
  • Fax: 859-655-6240

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number722
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: