Provider Demographics
NPI:1174634992
Name:POWELL, JAMES MULLER (LICSW)
Entity Type:Individual
Prefix:
First Name:JAMES
Middle Name:MULLER
Last Name:POWELL
Suffix:
Gender:M
Credentials:LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:673 LOIS LN
Mailing Address - Street 2:
Mailing Address - City:LINO LAKES
Mailing Address - State:MN
Mailing Address - Zip Code:55014-5498
Mailing Address - Country:US
Mailing Address - Phone:612-648-8583
Mailing Address - Fax:651-784-7761
Practice Address - Street 1:7362 UNIVERSITY AVE NE
Practice Address - Street 2:SUITE 101
Practice Address - City:FRIDLEY
Practice Address - State:MN
Practice Address - Zip Code:55432-3142
Practice Address - Country:US
Practice Address - Phone:763-503-3981
Practice Address - Fax:763-503-3981
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-31
Last Update Date:2008-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN004461041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN16M91POOtherBLUE CROSS
MN384824800Medicaid
MN384824800Medicaid