Provider Demographics
NPI:1154120418
Name:POWLESS, MENISSA RITA (SAC-IT)
Entity type:Individual
Prefix:
First Name:MENISSA
Middle Name:RITA
Last Name:POWLESS
Suffix:
Gender:
Credentials:SAC-IT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2041 VIKING DR
Mailing Address - Street 2:
Mailing Address - City:REEDSBURG
Mailing Address - State:WI
Mailing Address - Zip Code:53959-8900
Mailing Address - Country:US
Mailing Address - Phone:608-355-1240
Mailing Address - Fax:608-355-9588
Practice Address - Street 1:S2845 WHITE EAGLE RD
Practice Address - Street 2:
Practice Address - City:BARABOO
Practice Address - State:WI
Practice Address - Zip Code:53913-9064
Practice Address - Country:US
Practice Address - Phone:608-355-1240
Practice Address - Fax:608-355-9588
Is Sole Proprietor?:No
Enumeration Date:2025-03-10
Last Update Date:2025-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI20718-130101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)