Basic Information
| Provider Information | |||||||||
| NPI: | 1043882889 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | POWLEN | ||||||||
| FirstName: | MIKAYLA | ||||||||
| MiddleName: | ELIZABETH | ||||||||
| NamePrefix: | MISS | ||||||||
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| Mailing Information | |||||||||
| Address1: | 8748 N 90 E | ||||||||
| Address2: | |||||||||
| City: | BURROWS | ||||||||
| State: | IN | ||||||||
| PostalCode: | 46916 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7654212780 | ||||||||
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| Practice Location | |||||||||
| Address1: | 940 LASLEY DR | ||||||||
| Address2: | |||||||||
| City: | LEBANON | ||||||||
| State: | IN | ||||||||
| PostalCode: | 460521480 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8887141927 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 07/12/2021 | ||||||||
| LastUpdateDate: | 07/12/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 06/15/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 221700000X | IN | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Art Therapist |
No ID Information.