Provider Demographics
NPI:1528425824
Name:POWELL, SANDRA
Entity type:Individual
Prefix:
First Name:SANDRA
Middle Name:
Last Name:POWELL
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:601 5TH AVE
Mailing Address - Street 2:
Mailing Address - City:PARKESBURG
Mailing Address - State:PA
Mailing Address - Zip Code:19365-1413
Mailing Address - Country:US
Mailing Address - Phone:610-857-5687
Mailing Address - Fax:
Practice Address - Street 1:601 5TH AVE
Practice Address - Street 2:
Practice Address - City:PARKESBURG
Practice Address - State:PA
Practice Address - Zip Code:19365-1413
Practice Address - Country:US
Practice Address - Phone:610-857-5687
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-01-19
Last Update Date:2016-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA103TM1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TM1800XBehavioral Health & Social Service ProvidersPsychologistIntellectual & Developmental Disabilities