Healthcare Provider Details

I. General information

NPI: 1154714418
Provider Name (Legal Business Name): MARYKAY POWELL ADDICTIONS COUNSELOR
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/11/2015
Last Update Date: 08/07/2023
Certification Date: 08/07/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1917 E PLEASANT VALLEY BLVD
ALTOONA PA
16602-7552
US

IV. Provider business mailing address

128 57TH ST
ALTOONA PA
16602-5002
US

V. Phone/Fax

Practice location:
  • Phone: 814-201-2355
  • Fax: 814-201-2355
Mailing address:
  • Phone: 814-937-6889
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number20-05-16
License Number StateOR
# 2
Primary TaxonomyN
Taxonomy Code175T00000X
TaxonomyPeer Specialist
License Number
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: