Healthcare Provider Details

I. General information

NPI: 1578065256
Provider Name (Legal Business Name): POWEIELATEI MARY NKENGLA LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: POWEIELATEI MARY IYEGHA

II. Dates (important events)

Enumeration Date: 03/08/2018
Last Update Date: 03/08/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

224 GREAT BRIDGE BLVD
CHESAPEAKE VA
23320-3904
US

IV. Provider business mailing address

7079 KIRBY CRES
NORFOLK VA
23505-4214
US

V. Phone/Fax

Practice location:
  • Phone: 757-547-9334
  • Fax: 757-819-6292
Mailing address:
  • Phone: 334-221-2204
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number4020C
License Number StateAL
# 2
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number0904010217
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: