Healthcare Provider Details

I. General information

NPI: 1891405353
Provider Name (Legal Business Name): SHANTEL LORRAINE POWELL PHD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/24/2022
Last Update Date: 11/24/2022
Certification Date: 11/24/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6 S LAKE AVE APT N2
ALBANY NY
12203-1137
US

IV. Provider business mailing address

6 S LAKE AVE APT N2
ALBANY NY
12203-1137
US

V. Phone/Fax

Practice location:
  • Phone: 772-370-4556
  • Fax:
Mailing address:
  • Phone: 772-370-4556
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC1900X
TaxonomyCounseling Psychologist
License Number024999
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: