Provider Demographics
NPI:1174197016
Name:POWELL, JOEY
Entity Type:Individual
Prefix:
First Name:JOEY
Middle Name:
Last Name:POWELL
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1518 METRO DR
Mailing Address - Street 2:
Mailing Address - City:SCHOFIELD
Mailing Address - State:WI
Mailing Address - Zip Code:54476-2380
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1518 METRO DR
Practice Address - Street 2:
Practice Address - City:SCHOFIELD
Practice Address - State:WI
Practice Address - Zip Code:54476-2380
Practice Address - Country:US
Practice Address - Phone:715-216-3760
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-05-15
Last Update Date:2021-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI918-58103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool