Provider Demographics
NPI:1760520860
Name:POWELL, RYLAND BOULDIN SR (LCSW)
Entity Type:Individual
Prefix:MR
First Name:RYLAND
Middle Name:BOULDIN
Last Name:POWELL
Suffix:SR
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:74 PARKER AVE
Mailing Address - Street 2:
Mailing Address - City:MAPLEWOOD
Mailing Address - State:NJ
Mailing Address - Zip Code:07040-1746
Mailing Address - Country:US
Mailing Address - Phone:973-763-2155
Mailing Address - Fax:973-763-6225
Practice Address - Street 1:74 PARKER AVE
Practice Address - Street 2:
Practice Address - City:MAPLEWOOD
Practice Address - State:NJ
Practice Address - Zip Code:07040-1746
Practice Address - Country:US
Practice Address - Phone:973-763-2155
Practice Address - Fax:973-763-6225
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ44SC000173001041C0700X
NJ37F100055500106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Not Answered106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
11234975OtherCIGNA BEHAV.HEALTH