Basic Information
Provider Information | |||||||||
NPI: | 1043799190 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | POWDRILL | ||||||||
FirstName: | KAREN | ||||||||
MiddleName: | YVONNE | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 10724 CORDAGE WALK | ||||||||
Address2: |   | ||||||||
City: | COLUMBIA | ||||||||
State: | MD | ||||||||
PostalCode: | 210443641 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4432202914 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 1900 N HOWARD ST STE 300 | ||||||||
Address2: |   | ||||||||
City: | BALTIMORE | ||||||||
State: | MD | ||||||||
PostalCode: | 212185909 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4434386742 | ||||||||
FaxNumber: | 4437735624 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 08/09/2018 | ||||||||
LastUpdateDate: | 08/09/2018 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YP2500X | LC8877 | MD | Y |   | Behavioral Health & Social Service Providers | Counselor | Professional |
ID Information
ID | Type | State | Issuer | Description | 38-3876389 | 05 | MD |   | MEDICAID |