Provider Demographics
NPI:1366506313
Name:POWELL, SERENA (NCTMB)
Entity Type:Individual
Prefix:
First Name:SERENA
Middle Name:
Last Name:POWELL
Suffix:
Gender:F
Credentials:NCTMB
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1261 CHIPETA AVE
Mailing Address - Street 2:
Mailing Address - City:GRAND JUNCTION
Mailing Address - State:CO
Mailing Address - Zip Code:81501-4435
Mailing Address - Country:US
Mailing Address - Phone:970-254-1352
Mailing Address - Fax:970-254-1352
Practice Address - Street 1:1000 N 9TH ST STE 7
Practice Address - Street 2:
Practice Address - City:GRAND JUNCTION
Practice Address - State:CO
Practice Address - Zip Code:81501-3107
Practice Address - Country:US
Practice Address - Phone:970-254-1352
Practice Address - Fax:970-254-1352
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO558225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist