Provider Demographics
NPI:1629461504
Name:POWELL, ROBERT (MS)
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:
Last Name:POWELL
Suffix:
Gender:M
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2513 5TH ST
Mailing Address - Street 2:
Mailing Address - City:PERU
Mailing Address - State:IL
Mailing Address - Zip Code:61354-2401
Mailing Address - Country:US
Mailing Address - Phone:815-343-2440
Mailing Address - Fax:
Practice Address - Street 1:2513 5TH ST
Practice Address - Street 2:
Practice Address - City:PERU
Practice Address - State:IL
Practice Address - Zip Code:61354-2401
Practice Address - Country:US
Practice Address - Phone:815-343-2440
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-03-16
Last Update Date:2015-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP1600XBehavioral Health & Social Service ProvidersCounselorPastoral
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health