Provider Demographics
NPI:1154714418
Name:POWELL, MARYKAY (ADDICTIONS COUNSELOR)
Entity type:Individual
Prefix:MRS
First Name:MARYKAY
Middle Name:
Last Name:POWELL
Suffix:
Gender:F
Credentials:ADDICTIONS COUNSELOR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:128 57TH ST
Mailing Address - Street 2:
Mailing Address - City:ALTOONA
Mailing Address - State:PA
Mailing Address - Zip Code:16602-5002
Mailing Address - Country:US
Mailing Address - Phone:814-937-6889
Mailing Address - Fax:
Practice Address - Street 1:1917 E PLEASANT VALLEY BLVD
Practice Address - Street 2:
Practice Address - City:ALTOONA
Practice Address - State:PA
Practice Address - Zip Code:16602-7552
Practice Address - Country:US
Practice Address - Phone:814-201-2355
Practice Address - Fax:814-201-2355
Is Sole Proprietor?:No
Enumeration Date:2015-03-11
Last Update Date:2023-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR175T00000X
OR20-05-16101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No175T00000XOther Service ProvidersPeer Specialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR20-05-16OtherMHACBO