=====================================================
General NPI Number Information
=====================================================
NPI Number | 1811747728
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | POWELL THERAPEUTICS, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/25/2024
-----------------------------------------------------
Last Update Date | 12/10/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1805 CHANTILLY ST STE 126
-----------------------------------------------------
City | RICHMOND
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 23230-3501
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 757-254-4644
-----------------------------------------------------
Fax | 804-621-7103
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 101 NEW HARVEST DR
-----------------------------------------------------
City | HENRICO
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 23231-5172
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 757-254-4644
-----------------------------------------------------
Fax | 804-621-7103
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | MISS PATRICE RENA POWELL
-----------------------------------------------------
Credential | LPC, LSATP, CSAC
-----------------------------------------------------
Telephone | 757-254-4644
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YM0800X
-----------------------------------------------------
Taxonomy Name | Mental Health Counselor
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 251S00000X
-----------------------------------------------------
Taxonomy Name | Community/Behavioral Health Agency
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------