1619476330 NPI number — KEINETHA CAMILLE POWERS LPC

Table of content: KEINETHA CAMILLE POWERS LPC (NPI 1619476330)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1619476330 NPI number — KEINETHA CAMILLE POWERS LPC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
POWERS
Provider First Name:
KEINETHA
Provider Middle Name:
CAMILLE
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
LPC
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
POWERS
Provider Other First Name:
MIA
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
LPC, NCC, CPCS
Provider Other Last Name Type Code:
2

NPI Number Information

NPI Number:
1619476330
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/06/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
5686 FULTON INDUSTRIAL BLVD SW
Provider Second Line Business Mailing Address:
UNIT 44528
Provider Business Mailing Address City Name:
ATLANTA
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
30336-3584
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
404-914-4782
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2001 MARTIN LUTHER KING JR DR SW STE 540
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ATLANTA
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
30310-1101
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
888-718-2827
Provider Business Practice Location Address Fax Number:
833-332-9827
Provider Enumeration Date:
02/08/2018

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 101YP2500X , with the licence number:  LPC009897 , registered in the state of GA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)