Healthcare Provider Details

I. General information

NPI: 1174856942
Provider Name (Legal Business Name): MICHAEL J POWELL M.A., ED.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/11/2009
Last Update Date: 11/06/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

173 RIDGEVIEW DR
BERKELEY SPRINGS WV
25411-5188
US

IV. Provider business mailing address

173 RIDGEVIEW DR
BERKELEY SPRINGS WV
25411-5188
US

V. Phone/Fax

Practice location:
  • Phone: 304-923-3650
  • Fax:
Mailing address:
  • Phone: 304-923-3650
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TS0200X
TaxonomySchool Psychologist
License Number22066
License Number StateWV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: