Provider Demographics
NPI:1316363781
Name:POWELL PEDIATRIC THERAPY
Entity Type:Organization
Organization Name:POWELL PEDIATRIC THERAPY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:CHANTEL
Authorized Official - Middle Name:ROSE
Authorized Official - Last Name:POWELL
Authorized Official - Suffix:
Authorized Official - Credentials:MOT
Authorized Official - Phone:760-685-7694
Mailing Address - Street 1:3185 CARR DR
Mailing Address - Street 2:
Mailing Address - City:OCEANSIDE
Mailing Address - State:CA
Mailing Address - Zip Code:92056
Mailing Address - Country:US
Mailing Address - Phone:760-685-7694
Mailing Address - Fax:760-692-1466
Practice Address - Street 1:3185 CARR DR
Practice Address - Street 2:
Practice Address - City:OCEANSIDE
Practice Address - State:CA
Practice Address - Zip Code:92056
Practice Address - Country:US
Practice Address - Phone:760-685-7694
Practice Address - Fax:760-692-1466
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-03-10
Last Update Date:2018-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA10089174400000X, 225XP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Multi-Specialty
No225XP0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPediatricsGroup - Multi-Specialty