Healthcare Provider Details

I. General information

NPI: 1437778750
Provider Name (Legal Business Name): POWELL CUCCHIELLA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/16/2020
Last Update Date: 04/16/2020
Certification Date: 04/16/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

260 WASHINGTON AVENUE EXT STE 101
ALBANY NY
12203-6326
US

IV. Provider business mailing address

12 BEACON ST
BALLSTON SPA NY
12020-3602
US

V. Phone/Fax

Practice location:
  • Phone: 518-218-1188
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number009730
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: