Provider Demographics
NPI:1083767495
Name:POWELL, RONALD O (PHD)
Entity Type:Individual
Prefix:
First Name:RONALD
Middle Name:O
Last Name:POWELL
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8201 164TH AVE NE
Mailing Address - Street 2:SUITE 200
Mailing Address - City:REDMOND
Mailing Address - State:WA
Mailing Address - Zip Code:98052-7615
Mailing Address - Country:US
Mailing Address - Phone:425-214-3609
Mailing Address - Fax:
Practice Address - Street 1:8201 164TH AVE NE
Practice Address - Street 2:SUITE 200
Practice Address - City:REDMOND
Practice Address - State:WA
Practice Address - Zip Code:98052-7615
Practice Address - Country:US
Practice Address - Phone:425-214-3609
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-19
Last Update Date:2015-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPY00001122103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA1083767495OtherNATIONAL PLAN AND PROVIDER ENUMERATION
WAR87987Medicare UPIN
WAG000135822Medicare PIN
WAG000135822Medicare PIN
WAR87987Medicare UPIN