Provider Demographics
NPI:1699805929
Name:POWELL, BRADLEY DOUGLAS (PHD)
Entity Type:Individual
Prefix:
First Name:BRADLEY
Middle Name:DOUGLAS
Last Name:POWELL
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2400 BROADMOOR DR STE C
Mailing Address - Street 2:
Mailing Address - City:BRYAN
Mailing Address - State:TX
Mailing Address - Zip Code:77802-2870
Mailing Address - Country:US
Mailing Address - Phone:979-774-9255
Mailing Address - Fax:970-774-9299
Practice Address - Street 1:2400 BROADMOOR DR STE C
Practice Address - Street 2:
Practice Address - City:BRYAN
Practice Address - State:TX
Practice Address - Zip Code:77802-2870
Practice Address - Country:US
Practice Address - Phone:979-774-9255
Practice Address - Fax:970-774-9299
Is Sole Proprietor?:No
Enumeration Date:2007-03-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX32062103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX00988WMedicare ID - Type Unspecified
TXB1005099Medicare UPIN