MEDICARE: MISS CHARLENE L POWELL SAP, LCAS, CADC,

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	101YA0400X	Addiction (Substance Use Disorder) Counselor	20639	NC

General Provider Information

NPI Number	:	1205340734
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MISS CHARLENE L POWELL SAP, LCAS, CADC,

Provider Business Mailing Address
First Line	:	2409 DAN AND MARY ST
Second Line	:
City	:	ELIZABETH CITY
State	:	NC
Zip	:	27909-9085
Country	:	US
Telephone Number	:	252-312-9572
Fax Number	:

Provider Business Practice Location Address
First Line	:	2409 DAN AND MARY ST
Second Line	:
City	:	ELIZABETH CITY
State	:	NC
Zip	:	27909-9085
Country	:	US
Telephone Number	:	252-312-9572
Fax Number	:

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

Provider Enumeration Date	:	11/20/2017
Last Update Date	:	11/10/2022

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