Provider Demographics
NPI:1922158146
Name:POWELL, WILLIE (MSW PA)
Entity type:Individual
Prefix:
First Name:WILLIE
Middle Name:
Last Name:POWELL
Suffix:
Gender:M
Credentials:MSW PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2115 MILLBURN AVE STE 100
Mailing Address - Street 2:
Mailing Address - City:MAPLEWOOD
Mailing Address - State:NJ
Mailing Address - Zip Code:07040-3724
Mailing Address - Country:US
Mailing Address - Phone:973-763-8123
Mailing Address - Fax:973-763-8243
Practice Address - Street 1:2115 MILLBURN AVE STE 100
Practice Address - Street 2:
Practice Address - City:MAPLEWOOD
Practice Address - State:NJ
Practice Address - Zip Code:07040-3724
Practice Address - Country:US
Practice Address - Phone:973-763-8123
Practice Address - Fax:973-763-8243
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-11
Last Update Date:2024-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJSC12965106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ223167686OtherTAX ID
NJ223167686OtherTAX ID