Basic Information
| Provider Information | |||||||||
| NPI: | 1215574900 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | POWELL | ||||||||
| FirstName: | MATTHEW | ||||||||
| MiddleName: | ALLEN | ||||||||
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| Mailing Information | |||||||||
| Address1: | 9714 HEALTHWAY DR | ||||||||
| Address2: | |||||||||
| City: | BERLIN | ||||||||
| State: | MD | ||||||||
| PostalCode: | 218111154 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4106413340 | ||||||||
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| Practice Location | |||||||||
| Address1: | 100 E CARROLL ST | ||||||||
| Address2: | |||||||||
| City: | SALISBURY | ||||||||
| State: | MD | ||||||||
| PostalCode: | 218015422 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4107268308 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 12/02/2019 | ||||||||
| LastUpdateDate: | 11/12/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 11/12/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | 21432 | MD | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
ID Information
| ID | Type | State | Issuer | Description | 21432 | 01 | MD | MARYLAND BOARD OF SOCIAL WORK | OTHER |