Provider Demographics
NPI:1265641047
Name:POWELL, PATRICIA LYNN (DT)
Entity Type:Individual
Prefix:MS
First Name:PATRICIA
Middle Name:LYNN
Last Name:POWELL
Suffix:
Gender:F
Credentials:DT
Other - Prefix:MRS
Other - First Name:PATRICIA
Other - Middle Name:LYNN
Other - Last Name:FRANKLIN
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:DT
Mailing Address - Street 1:8051 OLD MORO RD
Mailing Address - Street 2:
Mailing Address - City:MORO
Mailing Address - State:IL
Mailing Address - Zip Code:62067-1057
Mailing Address - Country:US
Mailing Address - Phone:618-377-0708
Mailing Address - Fax:618-377-2664
Practice Address - Street 1:8051 OLD MORO RD
Practice Address - Street 2:
Practice Address - City:MORO
Practice Address - State:IL
Practice Address - Zip Code:62067-1057
Practice Address - Country:US
Practice Address - Phone:618-377-0708
Practice Address - Fax:618-377-2664
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ILPF52540602P222Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental Therapist