Provider Demographics
NPI:1639891989
Name:POWELL, PAYTON OLIVIA
Entity Type:Individual
Prefix:
First Name:PAYTON
Middle Name:OLIVIA
Last Name:POWELL
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:719 SPENCER ST
Mailing Address - Street 2:
Mailing Address - City:LOGANSPORT
Mailing Address - State:IN
Mailing Address - Zip Code:46947-3583
Mailing Address - Country:US
Mailing Address - Phone:765-513-9691
Mailing Address - Fax:
Practice Address - Street 1:719 SPENCER ST
Practice Address - Street 2:
Practice Address - City:LOGANSPORT
Practice Address - State:IN
Practice Address - Zip Code:46947-3583
Practice Address - Country:US
Practice Address - Phone:765-513-9691
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-09-14
Last Update Date:2022-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN3850103248106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
Provider Identifiers
StateIdentifier IDID TypeIssuer
INRBT-21-177553OtherBEHAVIOR ANALYST CERTIFICATION BOARD