Provider Demographics
NPI:1457485310
Name:POWELL, LARRY CLINTON (LMFT)
Entity Type:Individual
Prefix:
First Name:LARRY
Middle Name:CLINTON
Last Name:POWELL
Suffix:
Gender:M
Credentials:LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:540 PATTON AVE
Mailing Address - Street 2:
Mailing Address - City:SAN JOSE
Mailing Address - State:CA
Mailing Address - Zip Code:95128-2150
Mailing Address - Country:US
Mailing Address - Phone:408-256-0459
Mailing Address - Fax:408-457-7190
Practice Address - Street 1:1769 PARK AVE STE 210
Practice Address - Street 2:
Practice Address - City:SAN JOSE
Practice Address - State:CA
Practice Address - Zip Code:95126-2025
Practice Address - Country:US
Practice Address - Phone:408-256-0459
Practice Address - Fax:408-457-7190
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-15
Last Update Date:2014-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YM0800X
CAMFC 46424106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health