Provider Demographics
NPI:1104655174
Name:POWELL-EDWARDS, DELTRESE DUNDRIENNE (MA)
Entity type:Individual
Prefix:MRS
First Name:DELTRESE
Middle Name:DUNDRIENNE
Last Name:POWELL-EDWARDS
Suffix:
Gender:F
Credentials:MA
Other - Prefix:MRS
Other - First Name:DELTRESE
Other - Middle Name:DUNDRIENNE
Other - Last Name:EDWARDS
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MA
Mailing Address - Street 1:2322 CHERRYLAWN AVE
Mailing Address - Street 2:
Mailing Address - City:BLOOMFIELD HILLS
Mailing Address - State:MI
Mailing Address - Zip Code:48302-0229
Mailing Address - Country:US
Mailing Address - Phone:310-714-6287
Mailing Address - Fax:
Practice Address - Street 1:2075 W BIG BEAVER RD STE 520
Practice Address - Street 2:
Practice Address - City:TROY
Practice Address - State:MI
Practice Address - Zip Code:48084-3442
Practice Address - Country:US
Practice Address - Phone:248-646-6659
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-07-29
Last Update Date:2024-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6451023758101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health