Provider Demographics
NPI:1417659509
Name:POWELL, GAVIN LANCE (MASSAGE THERAPIST)
Entity Type:Individual
Prefix:
First Name:GAVIN
Middle Name:LANCE
Last Name:POWELL
Suffix:
Gender:M
Credentials:MASSAGE THERAPIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 250435
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10025-1524
Mailing Address - Country:US
Mailing Address - Phone:810-835-9314
Mailing Address - Fax:
Practice Address - Street 1:630 W 173RD ST
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10032-1413
Practice Address - Country:US
Practice Address - Phone:810-835-9314
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-03-21
Last Update Date:2023-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAMT014426225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist