Healthcare Provider Details

I. General information

NPI: 1023528247
Provider Name (Legal Business Name): JOHANNA MOMAN POWELL
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/02/2017
Last Update Date: 07/13/2026
Certification Date: 07/13/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5210 14TH AVE SE
LACEY WA
98503-2429
US

IV. Provider business mailing address

5210 14TH AVE SE
LACEY WA
98503-2429
US

V. Phone/Fax

Practice location:
  • Phone: 615-335-3328
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number1007
License Number StateTN
# 2
Primary TaxonomyN
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number60985288
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: