Provider Demographics
NPI:1144404419
Name:POWELL, DOROTHY JULIETTE (PSYD)
Entity Type:Individual
Prefix:MS
First Name:DOROTHY
Middle Name:JULIETTE
Last Name:POWELL
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:DR
Other - First Name:DOROTHY
Other - Middle Name:JULIETTE
Other - Last Name:POWELL
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:PSYD
Mailing Address - Street 1:3301 E 12TH ST
Mailing Address - Street 2:SUITE 259
Mailing Address - City:OAKLAND
Mailing Address - State:CA
Mailing Address - Zip Code:94601-3424
Mailing Address - Country:US
Mailing Address - Phone:510-269-9103
Mailing Address - Fax:510-269-9031
Practice Address - Street 1:3301 E 12TH ST
Practice Address - Street 2:SUITE 259
Practice Address - City:OAKLAND
Practice Address - State:CA
Practice Address - Zip Code:94601-3424
Practice Address - Country:US
Practice Address - Phone:510-269-9103
Practice Address - Fax:510-269-9031
Is Sole Proprietor?:Yes
Enumeration Date:2007-12-21
Last Update Date:2007-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSB 29250103TC2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & Adolescent