Provider Demographics
NPI:1376283515
Name:POWERS, PAYTON (MA CCC-SLP)
Entity Type:Individual
Prefix:
First Name:PAYTON
Middle Name:
Last Name:POWERS
Suffix:
Gender:M
Credentials:MA CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:102 CLARK PL APT 1
Mailing Address - Street 2:
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38104-2419
Mailing Address - Country:US
Mailing Address - Phone:901-282-9090
Mailing Address - Fax:
Practice Address - Street 1:4075 PARK AVE, MEMPHIS
Practice Address - Street 2:
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38152
Practice Address - Country:US
Practice Address - Phone:901-282-9090
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-03-29
Last Update Date:2022-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN7398235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN7398OtherSLP TN STATE LICENSE