=====================================================
General NPI Number Information
=====================================================
NPI Number | 1245528470
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MY MENTAL WELLNESS, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/21/2011
-----------------------------------------------------
Last Update Date | 12/18/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2015 ASTILBE WAY
-----------------------------------------------------
City | ODENTON
-----------------------------------------------------
State | MD
-----------------------------------------------------
Zip | 21113-2931
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 301-642-5133
-----------------------------------------------------
Fax | 443-230-3536
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2015 ASTILBE WAY
-----------------------------------------------------
City | ODENTON
-----------------------------------------------------
State | MD
-----------------------------------------------------
Zip | 21113-2931
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 301-642-5133
-----------------------------------------------------
Fax | 443-230-3536
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DR. NORMA FAYE POWELL
-----------------------------------------------------
Credential | PHD
-----------------------------------------------------
Telephone | 301-642-5133
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YM0800X
-----------------------------------------------------
Taxonomy Name | Mental Health Counselor
-----------------------------------------------------
License Number | LC2311
-----------------------------------------------------
License Number State | MD
-----------------------------------------------------