Provider Demographics
NPI:1255654224
Name:POWELL ACQUSITION COMPANY
Entity Type:Organization
Organization Name:POWELL ACQUSITION COMPANY
Other - Org Name:POWELL & WAGNER ASSOCIATES, INC.
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:KARL
Authorized Official - Middle Name:
Authorized Official - Last Name:WAGNER
Authorized Official - Suffix:
Authorized Official - Credentials:PSYD
Authorized Official - Phone:617-494-1650
Mailing Address - Street 1:875 MASSACHUSETTS AVE
Mailing Address - Street 2:SUITE 84
Mailing Address - City:CAMBRIDGE
Mailing Address - State:MA
Mailing Address - Zip Code:02139-3067
Mailing Address - Country:US
Mailing Address - Phone:617-494-1650
Mailing Address - Fax:617-494-1975
Practice Address - Street 1:875 MASSACHUSETTS AVE
Practice Address - Street 2:SUITE 84
Practice Address - City:CAMBRIDGE
Practice Address - State:MA
Practice Address - Zip Code:02139-3067
Practice Address - Country:US
Practice Address - Phone:617-494-1650
Practice Address - Fax:617-494-1975
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-03-05
Last Update Date:2010-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA7433103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Multi-Specialty