Provider Demographics
NPI:1083716559
Name:POWELL, CONNIE G (PSYD)
Entity Type:Individual
Prefix:DR
First Name:CONNIE
Middle Name:G
Last Name:POWELL
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:521 W HORNER ST APT 5
Mailing Address - Street 2:
Mailing Address - City:EBENSBURG
Mailing Address - State:PA
Mailing Address - Zip Code:15931-1357
Mailing Address - Country:US
Mailing Address - Phone:814-243-9129
Mailing Address - Fax:
Practice Address - Street 1:1993 CATO AVE
Practice Address - Street 2:
Practice Address - City:STATE COLLEGE
Practice Address - State:PA
Practice Address - Zip Code:16801-2754
Practice Address - Country:US
Practice Address - Phone:814-231-8820
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPS016032103TC0700X
IN20041900A103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical