Provider Demographics
NPI:1124231535
Name:POWELL, IAN (MS, CCC-SLP)
Entity Type:Individual
Prefix:
First Name:IAN
Middle Name:
Last Name:POWELL
Suffix:
Gender:M
Credentials:MS, CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:64696 E LUPINE DR
Mailing Address - Street 2:
Mailing Address - City:RHODODENDRON
Mailing Address - State:OR
Mailing Address - Zip Code:97049-9770
Mailing Address - Country:US
Mailing Address - Phone:503-789-3218
Mailing Address - Fax:
Practice Address - Street 1:12555 SW 3RD ST
Practice Address - Street 2:
Practice Address - City:BEAVERTON
Practice Address - State:OR
Practice Address - Zip Code:97005-0517
Practice Address - Country:US
Practice Address - Phone:503-789-3218
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR11865235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist