MEDICARE: STAISHA 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	106S00000X	Behavior Technician
2	106S00000X	Behavior Technician	22-208277	GA

General Provider Information

NPI Number	:	1891443776
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	STAISHA POWELL

Provider Business Mailing Address
First Line	:	2472 JETT FERRY RD
Second Line	:
City	:	ATLANTA
State	:	GA
Zip	:	30338-3059
Country	:	US
Telephone Number	:	678-691-2206
Fax Number	:

Provider Business Practice Location Address
First Line	:	2472 JETT FERRY RD
Second Line	:
City	:	ATLANTA
State	:	GA
Zip	:	30338-3059
Country	:	US
Telephone Number	:	678-691-2206
Fax Number	:

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

Provider Enumeration Date	:	03/10/2022
Last Update Date	:	05/05/2022

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Directions to “ STAISHA POWELL ” Practice Location

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