Provider Demographics
NPI:1326662685
Name:POWELL, ERIC DAVID (PHD)
Entity Type:Individual
Prefix:DR
First Name:ERIC
Middle Name:DAVID
Last Name:POWELL
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4230 GARDENDALE ST STE 502
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78229-3699
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4230 GARDENDALE ST STE 502
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78229-3699
Practice Address - Country:US
Practice Address - Phone:314-540-6067
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-06-02
Last Update Date:2020-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
103TH0004X, 103TH0100X
TX37727103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103TH0004XBehavioral Health & Social Service ProvidersPsychologistHealth
No103TH0100XBehavioral Health & Social Service ProvidersPsychologistHealth Service