MEDICARE: MRS. MARYKAY POWELL ADDICTIONS COUNSELOR

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	175T00000X	Peer Specialist		OR
2	101YA0400X	Addiction (Substance Use Disorder) Counselor	20-05-16	OR

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	20-05-16	OTHER	OR	MHACBO

General Provider Information

NPI Number	:	1154714418
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. MARYKAY POWELL ADDICTIONS COUNSELOR

Provider Business Mailing Address
First Line	:	128 57TH ST
Second Line	:
City	:	ALTOONA
State	:	PA
Zip	:	16602-5002
Country	:	US
Telephone Number	:	814-937-6889
Fax Number	:

Provider Business Practice Location Address
First Line	:	1917 E PLEASANT VALLEY BLVD
Second Line	:
City	:	ALTOONA
State	:	PA
Zip	:	16602-7552
Country	:	US
Telephone Number	:	814-201-2355
Fax Number	:	814-201-2355

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/11/2015
Last Update Date	:	08/07/2023

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