Provider Demographics
NPI:1508995945
Name:POWELL, MOSES (LMT)
Entity Type:Individual
Prefix:
First Name:MOSES
Middle Name:
Last Name:POWELL
Suffix:
Gender:M
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:536 FAIRVIEW AVE
Mailing Address - Street 2:
Mailing Address - City:BALDWIN
Mailing Address - State:NY
Mailing Address - Zip Code:11510-3705
Mailing Address - Country:US
Mailing Address - Phone:516-203-1264
Mailing Address - Fax:516-867-1162
Practice Address - Street 1:536 FAIRVIEW AVE
Practice Address - Street 2:
Practice Address - City:BALDWIN
Practice Address - State:NY
Practice Address - Zip Code:11510-3705
Practice Address - Country:US
Practice Address - Phone:516-203-1264
Practice Address - Fax:516-867-1162
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-02
Last Update Date:2022-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY010045225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist