MEDICARE: CORBREN NICHELLE POWELL

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	1041C0700X	Clinical Social Worker	P013423	NC

General Provider Information

NPI Number	:	1891337630
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	CORBREN NICHELLE POWELL

Provider Business Mailing Address
First Line	:	PO BOX 604050
Second Line	:
City	:	CHARLOTTE
State	:	NC
Zip	:	28260-4050
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	855 SAM NEWELL RD STE 204
Second Line	:
City	:	MATTHEWS
State	:	NC
Zip	:	28105-7594
Country	:	US
Telephone Number	:	980-202-6643
Fax Number	:	980-246-9482

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

Provider Enumeration Date	:	10/14/2019
Last Update Date	:	02/06/2025

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