Provider Demographics
NPI:1215163316
Name:POWELL, BENNY LEE (MDIV, LCAC)
Entity type:Individual
Prefix:
First Name:BENNY
Middle Name:LEE
Last Name:POWELL
Suffix:
Gender:M
Credentials:MDIV, LCAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:850 N HARRISON ST
Mailing Address - Street 2:ATTN: ANNE LAWSON - CREDENTIALING
Mailing Address - City:WARSAW
Mailing Address - State:IN
Mailing Address - Zip Code:46580-3163
Mailing Address - Country:US
Mailing Address - Phone:574-267-7169
Mailing Address - Fax:574-269-0597
Practice Address - Street 1:2100 GOSHEN RD
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46808-1493
Practice Address - Country:US
Practice Address - Phone:240-471-3500
Practice Address - Fax:260-471-4263
Is Sole Proprietor?:No
Enumeration Date:2009-06-03
Last Update Date:2010-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN87000082A101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)