Provider Demographics
NPI:1184698979
Name:POWELL, MARY R (LICSW)
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:R
Last Name:POWELL
Suffix:
Gender:F
Credentials:LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 337
Mailing Address - Street 2:NEW RIVER HEALTH ASSOCIATION INC
Mailing Address - City:SCARBRO
Mailing Address - State:WV
Mailing Address - Zip Code:25917-0337
Mailing Address - Country:US
Mailing Address - Phone:304-469-2905
Mailing Address - Fax:304-465-5486
Practice Address - Street 1:908 SCARBRO RD
Practice Address - Street 2:NEW RIVER HEALTH - SCARBRO
Practice Address - City:SCARBRO
Practice Address - State:WV
Practice Address - Zip Code:25917-8837
Practice Address - Country:US
Practice Address - Phone:304-469-2905
Practice Address - Fax:304-465-5486
Is Sole Proprietor?:No
Enumeration Date:2006-02-16
Last Update Date:2009-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WVDP00208400104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV3810000553Medicaid
WV3810000553Medicaid