Provider Demographics
NPI:1689185225
Name:POWELL, KRISTIE DELANE (MA)
Entity type:Individual
Prefix:MRS
First Name:KRISTIE
Middle Name:DELANE
Last Name:POWELL
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11125 PARK BLVD STE 104-279
Mailing Address - Street 2:
Mailing Address - City:SEMINOLE
Mailing Address - State:FL
Mailing Address - Zip Code:33772-4757
Mailing Address - Country:US
Mailing Address - Phone:727-900-5129
Mailing Address - Fax:
Practice Address - Street 1:12980 WALSINGHAM RD
Practice Address - Street 2:
Practice Address - City:LARGO
Practice Address - State:FL
Practice Address - Zip Code:33774-3511
Practice Address - Country:US
Practice Address - Phone:727-900-5129
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-10-23
Last Update Date:2024-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL104100000X251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health