Healthcare Provider Details

I. General information

NPI: 1710101035
Provider Name (Legal Business Name): MELANIE V POWELL PH.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/11/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

517 S SHARON AMITY RD STE 105
CHARLOTTE NC
28211-2894
US

IV. Provider business mailing address

11628 TAVERNAY PKWY
CHARLOTTE NC
28262-4477
US

V. Phone/Fax

Practice location:
  • Phone: 704-362-1555
  • Fax:
Mailing address:
  • Phone: 704-595-9204
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number2478
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: