MEDICARE: MS. PAMELA SUE POWERS LCSW, CAP, CCTP

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	3067	FL
2	1041C0700X	Clinical Social Worker	SW 11074	FL

General Provider Information

NPI Number	:	1669714002
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. PAMELA SUE POWERS LCSW, CAP, CCTP

Provider Business Mailing Address
First Line	:	412 SPANISH MOSS TRL
Second Line	:
City	:	DESTIN
State	:	FL
Zip	:	32541-2605
Country	:	US
Telephone Number	:	850-803-0079
Fax Number	:

Provider Business Practice Location Address
First Line	:	51B YACHT CLUB DR NE
Second Line	:
City	:	FORT WALTON BEACH
State	:	FL
Zip	:	32548-4473
Country	:	US
Telephone Number	:	850-664-0145
Fax Number	:

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

Provider Enumeration Date	:	03/25/2013
Last Update Date	:	03/25/2013

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