1952449472 NPI number — RANDALL STUART POWELL PSYD

Table of content: RANDALL STUART POWELL PSYD (NPI 1952449472)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1952449472 NPI number — RANDALL STUART POWELL PSYD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
POWELL
Provider First Name:
RANDALL
Provider Middle Name:
STUART
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
PSYD
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1952449472
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
224 VALLEY RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MERION STATION
Provider Business Mailing Address State Name:
PA
Provider Business Mailing Address Postal Code:
19066
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
610-667-4652
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
ONE BALA AVENUE
Provider Second Line Business Practice Location Address:
SUITE 305
Provider Business Practice Location Address City Name:
BALA CYNWYD
Provider Business Practice Location Address State Name:
PA
Provider Business Practice Location Address Postal Code:
19004
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
610-667-4652
Provider Business Practice Location Address Fax Number:
610-667-6418
Provider Enumeration Date:
02/05/2007

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 103T00000X , with the licence number:  DS004364L , registered in the state of PA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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